Management & Treatment Protocol - Tarakeswar Patel, 29Y/M, Left Knee MRI (18-07-2026)

Summary of Injuries (from MRI Report)

Phase 1 - Acute Management (Week 0-4)

Immediate Steps

1. Immobilize in a hinged knee brace - Set 0-90° range of motion. This is the standard of care for combined ACL+MCL injuries. The MCL and LCL have significant healing potential with bracing; the ACL does not. (ISAKOS 2026 consensus)
2. RICE protocol - Rest, Ice (20 min every 2-4 hours), Compression, Elevation for the first 72 hours.
3. Analgesia & anti-inflammatories - NSAIDs (e.g., Naproxen 500mg BD or Etoricoxib 60mg OD) for 5-7 days for pain and effusion control. Avoid prolonged use as it may impair bone healing of contusions.
4. Knee aspiration - If effusion is large and causing significant pain/restricted ROM, consider aspiration under sterile conditions. The MRI shows only "mild" collection, so this may not be immediately necessary.
5. Crutches / partial weight-bearing - Due to bone contusions in femoral condyles, tibial condyle, and fibular head, restrict full weight-bearing initially. Advance to full weight-bearing as tolerated over 2-4 weeks.
6. X-ray of left knee (AP + lateral) - Confirm no occult fracture of the fibular head (given bone contusion noted there). Fibular head avulsion fracture (arcuate sign) can be associated with LCL/posterolateral corner injuries and changes management.

Phase 2 - Decision on Surgical vs Non-Surgical ACL Management (Week 3-6 Assessment)

Indications Favoring ACL Reconstruction (ACLR)

• Age < 35 years - young, physically active patient
• Combined multiligament injury (ACL + LCL partial + MCL edema)
• High demand for return to sport or physical labour
• Risk of progressive cartilage damage and meniscal tears if instability persists
• Evidence: A 2025 systematic review (Filbay SR et al., PMID: 40603829) found no difference in return-to-sport between ACLR and rehab alone, but operative management remains preferred for young active patients with multiligament involvement who want high-level activity

Preferred Approach: Staged Protocol

• Both MCL (edema = grade I-II) and LCL (interstitial tear = grade II) have excellent healing potential with conservative management
• Hinged knee brace for 6 weeks, allowing controlled ROM 0-90°
• Progressive physiotherapy to regain ROM and quad strength
• The German Knee Society (DKG) consensus (Grade A1, 91% agreement) states that Grade I-II MCL tears in combined ACL/MCL injuries should be treated non-operatively

• If valgus and varus stress testing confirms collateral healing -> proceed to ACL reconstruction
• If persistent valgus/varus laxity -> consider simultaneous or staged MCL/LCL reconstruction alongside ACLR

Phase 3 - ACL Reconstruction (Usually at 6-12 Weeks Post-Injury)

Timing

• Best to delay until: effusion resolves, ROM restored to near-full, quad activation adequate ("prehab" completed). Operating on a stiff, swollen knee increases risk of arthrofibrosis.

Graft Choice (Discuss with patient)

Technique

• Anatomic single-bundle ACLR via arthroscopic approach
• Transtibial or anteromedial portal femoral tunnel drilling
• Address any intraoperative LCL/posterolateral corner laxity if confirmed at examination under anaesthesia
• Assess menisci and cartilage arthroscopically at time of surgery (MRI showed intact cartilage and menisci - confirm intraoperatively)

Phase 4 - Post-Operative Rehabilitation Protocol (ACLR Rehab, 9-12 Months)

Weeks 1-2 (Acute post-op)

• Hinged brace locked at 0°, crutches
• Quad sets, straight leg raises, ankle pumps
• Ice and elevation for swelling
• Wound care

Weeks 2-6

• Progressive ROM: 0-90° advancing to 0-120°
• Weight-bearing as tolerated progressing to full
• Closed kinetic chain (CKC) exercises: mini squats, wall slides, leg press
• Scar mobilization, patellar mobilization

Weeks 6-12

• Full weight-bearing, discontinue brace
• Stationary cycling, swimming (no breaststroke kick)
• Continue quad and hamstring strengthening

Months 3-6

• Proprioception and neuromuscular training
• Sport-specific conditioning begins
• Running programme introduced (typically at 3-4 months if quad strength >70% of contralateral leg)

Months 6-9+

• Return-to-sport testing (hop tests, isokinetic strength testing)
• Target: quad symmetry index >90%, hop test symmetry >90%
• Psychologically-assessed readiness for return to sport
• Typical return to sport: 9-12 months for cutting/pivoting sports

Incidental Enchondroma - Proximal Tibial Shaft (22x15mm)

1. Do not ignore - Though enchondroma is typically benign, a 22x15mm lesion in the tibia requires characterisation
2. Refer to orthopaedic oncology or a musculoskeletal tumour specialist for evaluation
3. Plain X-ray of tibia - Look for typical endosteal scalloping, chondroid matrix calcification ("rings and arcs" pattern)
4. Surveillance: If features are classic for enchondroma and the lesion is asymptomatic, active surveillance with repeat MRI at 6-12 months is appropriate
5. Biopsy is NOT routinely required for typical enchondromas but may be needed if features are atypical (size >5cm, endosteal scalloping >2/3 cortex thickness, periosteal reaction, pain at night - none of these appear to be present here)
6. Importantly, if ACLR surgery is planned, the tibial tunnel should be positioned to avoid the enchondroma - this needs to be discussed with the operating surgeon preoperatively

Summary Action List (Next Steps, in Order)

Important note: This management outline is based on the MRI findings and current orthopaedic evidence. Final decisions must be made by the treating orthopaedic surgeon after full clinical examination (Lachman test, anterior drawer, pivot shift, valgus/varus stress tests), assessment of patient's functional demands, and discussion of the enchondroma with an MSK oncology specialist. The MRI report itself states "Clinical Correlation Suggested."