Miller Maier: A 24-Year-Old Male With a Painful, Unsteady Right Knee Following a Skiing Accident

Learning Objectives

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Learn the common causes of knee pain.
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Develop an understanding of the unique anatomy of the knee joint.
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Develop an understanding of the bursae of the knee.
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Develop an understanding of the ligaments of the knee.
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Develop an understanding of the tendons of the knee.
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Develop an understanding of the differential diagnosis of knee pain.
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Learn the clinical presentation of anterior cruciate ligament injury.
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Learn how to examine the knee and associated ligaments.
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Learn how to use physical examination to identify anterior cruciate ligament injury.
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Develop an understanding of the treatment options for anterior cruciate ligament injury.

Miller Maier

Miller Maier is a 24-year-old accountant with the chief complaint of, “My right knee keeps giving out.” Miller stated that he was snow skiing at Big Bear last weekend when his right ski tip dug in, twisting his knee and causing him to fall “halfway down the mountain.” He said he heard a loud pop from his right knee as soon as his ski tip dug in. Miller said he was pretty shook up, so he just lay there for a while. When he got up, his right knee really hurt, but what really scared him was that he had a feeling that the knee was slipping backward. Miller said that by the time he got home, he had a huge bruise on the front of his right knee and it was swollen up about twice its normal size. He elevated his leg and used an ice pack, which seemed to help the swelling, but the “slipping backward” sensation and the knee pain continued. He took some of his partner’s pain pills, but all they did was make him feel like he was going to throw up all the time.

“Doctor, this crazy, unsteady feeling in my knee is really driving me crazy. At first I thought I just sprained it, and it would get better, but if anything the ‘slipping backward’ feeling is getting worse.” I asked Miller about any previous injuries to the right knee and he said, “In fact, I’m a damn good skier and have never had a serious fall. Doc, I can tough it through the pain, but the unsteady knee is really freaking me out. What the hell did I do to my knee?”

I asked Miller what made his symptoms worse and he said, “Anytime I put any weight on my right knee, I’m in trouble. I have been walking so funny that now my left knee is starting to bother me. Doctor, my knee is hurting all the time and the pain is really messing with my sleep because I just can’t seem to find a comfortable position. Every time I roll over onto my right side, the pain in my knee wakes me up.”

I asked Miller to point with one finger to show me where the snap came from and he pointed to the area in front of his right knee, just below the patella, and said, “Right here, Doc.”

On physical examination, Miller was afebrile. His respirations were 18 and his pulse was 64 and regular. His blood pressure was 118/40. His head, eyes, ears, nose, and throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal, as was his abdominal examination. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of the right knee revealed a resolving ecchymosis and moderate swelling. The area over the anterior knee was warm but did not appear to be infected. There was some tenderness with palpation of the patellar tendon. Examination of the bursae of the knee revealed no obvious bursitis. I performed an anterior drawer test, which was markedly positive on the right and negative on the left ( Fig. 4.1 ). The Lachman test for anterior cruciate ligament integrity was also positive ( Fig. 4.2 ). Range of motion of the knee joint, especially resisted extension of the joint, reproduced Miller’s pain. The left knee examination was normal as was examination of his other major joints. A careful neurologic examination of the upper and lower extremities revealed that there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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Onset of right knee pain and a backward sliding sensation of the knee following a ski injury
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An audible popping sound from the right knee at the time of injury
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Pain localized to the anterior knee
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No other specific traumatic event to the area identified
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No fever or chills
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Sleep disturbance

The Physical Examination

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The patient is afebrile
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There is a resolving ecchymosis over the anterior knee
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There is moderate swelling of the knee
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Tenderness to palpation of the patellar tendon on the right
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No evidence of infection
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Pain on resisted extension of the affected right knee
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The anterior drawer test was positive on the right (see Fig. 4.1 )
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The Lachman test was positive on the right (see Fig. 4.2 )

Other Findings of Note

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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper and lower extremity neurologic examination, motor and sensory examination
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No evidence of bursitis
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Examinations of joints other than the right knee were normal

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiographs of the right knee
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Ultrasound of the right knee
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Magnetic resonance imaging (MRI) of the right knee

Test Results

The plain radiographs of the right knee were reported as normal. Ultrasound examination of the right knee revealed complete disruption of the anterior cruciate ligament ( Fig. 4.3 ). MRI examination of the right knee demonstrated complete disruption of the anterior cruciate ligament with retraction from the femoral attachment site ( Fig. 4.4 ).