How to Evaluate Varus and Valgus Deformity of the Knee

Dear fellow Redditors, I am asking for your experiences and opinions.
What happened: A month ago, I was playing a competitive game of soccer. At one point I tried to reach a cross from a team mate. Unfortunatately the cross was a bit too long. I tried to reach for the ball and stuck out my leg. I did not have much muscle tension since I thought I wouldn't reach the ball. My leg was in the air (so foot not planted) and aprox. flexed 20 degrees, so almost extended, but not fully. So no valgus/varus position as well. The ball hit the tip of my foot and twisted my leg/knee outwards.
Initial symptoms: I had a sharp pain when the knee was twisted in the region of the medial meniscus. I felt the pain for about 5 minutes with every step but actually continued playing. Then the pain would subside. After the game the pain would return when bending the knee, walking down stairs or while squatting.
The next days: I had no swelling at all. The pain during the previously mentioned activities would stay for about a week or so. I went to the doctor 4 days after the incident. He examined my knee and told me that ligament-wise it feels stable. He diagnosed me with a sprained medial meniscus. I was told to avoid sports until the pain is completely gone. I would even see my physiotherapist and she told me my knee feels stable as well.
The problem now: My knee has felt "weird" ever since. If I had to describe the feeling, it is like there is a tension inside the knee which differs from the other knee. Further, there is a slight feeling of instability. Not to the point that my knee would actually give in. More like it feels like it would bend backwards but it actually doesn't. That feeling also only occurs when the knee is extended, so while standing or walking normally. I returned to soccer training this week and I had no pain. However I played very carefully because of the fear that my knee would give in. So I avoided sharp turns etc. There was some pain in the same medial meniscus region after the training, but it would recover 2 days afterwards.
My question: what causes that weird, unstable feeling in my knee? Might this be something caused by an ACL injury? And could the incident mechanism as described hurt my ACL at all? The last resort would be an MRI scan, however I do not want to pay heavy money for a scan that tells me that everything is fine. So I wanted to ask about your opinions on that story, maybe this will calm me down a bit.
Thanks.

Operative indications of tibial plateau fractures include varus/valgus instability > 10 degrees at full extension. However, from my understanding, collateral ligament repair is not commonly done in the acute operative setting.
I understand that there is increased risk of degeneration associated with knee instability, but I don't understand why is operation (I assume ORIF, and not the ligament repair) advised in tibial plateau fractures with ligamentous laxity, especially if the fracture is minimally displaced (or at least within the accepted ranges of articular stepping / displacement).

Overview of LCL Pathology
In patients who have a complete lateral or fibular collateral ligament (LCL) tear and noticeable side-to-side instability with activities, a lateral collateral ligament surgery is recommended. The term fibular collateral ligament (FCL) is more anatomically correct, but is more commonly referred to as lateral collateral ligament (LCL).
LCL surgery is very effective in restoring side-to-side stability to the knee and preventing varus gapping. During a clinical exam and varus stress radiographs, we will be able to confirm whether or not there is a complete LCL tear. It is important to note that an MRI scan can be inaccurate – especially in cases of a chronic situation where the LCL heals improperly – that is why it is important to properly analyze the pathology.
Treatment for LCL Injury
The severity of the LCL injury will determine the treatment method. In less severe cases, a remedy of rest, ice, compression, and elevation (RICE) along with the use of anti-inflammatory medications (NSAIDs) and pain relievers can alleviate discomfort and help diminish swelling. Increasing strength and range-of-motion can be achieved through physical therapy, and ultimately restore the knee back to a healthy state.
Typically, patients who have a complete LCL tear will require surgical treatment. This surgical procedure is typically done as an open procedure in conjunct with arthroscopy. Dr. Miten Sheth from The Knee Clinic will replace the torn lateral collateral ligament with a tissue graft. The graft is passed through the bone tunnels and attached to the femur and fibula bone using screws.
We prefer an anatomic technique for surgical reconstruction. With this technique, we use either autograft hamstring tendon to reconstruct the lateral collateral ligament between its native course. First, a tunnel is reamed at the femoral attachment site, slightly proximal and posterior to the lateral epicondyle. We then secure the graft at this location with an interference screw in the prepared tunnel. The graft is then passed under the superficial layer of the iliotibial band and the lateral aponeurosis of the long head of the biceps femoris. Next, a tunnel is reamed through the fibular head, starting laterally at the exact attachment site of the LCL on the fibular head, and exits on the medial aspect of the fibular styloid just distal to the popliteofibular ligament. The graft is then passed through this. The graft is placed under tension, the knee is flexed to 20 degrees and a valgus reduction force is applied. A screw is then used to attach the graft in the fibular head. Once one confirms on exam under anesthesia that the varus gapping is eliminated, the procedure can then be ended.
Are you a candidate for LCL Reconstruction?
There are two ways to initiate a consultation with Dr. Sheth:
1. You can provide X-rays and/or MRIs for a clinical case review with Dr. Sheth.
2. You can schedule an OPD consultation.
REQUEST CASE REVIEW OR OPD CONSULTATION
(Please keep reading below for more information on this treatment.)
Post-Operative Protocol for LCL Surgery
Rehabilitation for LCL surgery involves early range of motion of the knee, starting at a minimum of 0 to 90 degrees the first day, and then after 2 weeks progressing further. Isolated hamstring exercises should be avoided for the first 4 months post-operatively. Patients should not place weight on the injured leg for 6 weeks and then may progress to crutches and start the use of a stationary bike starting at week 6. They should avoid side-to-side activities, or step-up activities, until varus stress X-rays are obtained at 5 months post-operatively verify that there is sufficient healing of the reconstruction graft to allow further activities. For athletes, we usually recommend the use of a secure brace to allow them to initiate these activities and request that they wear it through the first year after surgery to maximize graft healing.

Hello DubNation!
As Steph's injury seems to have caused all sorts of heartache, stress, nervous tension, anxiety, and the like, to this community, I wanted to address this diagnosis to help further our understanding and hopefully enlighten a few individuals into our beloved leader's current situation. I am not an MD. I am a doctor of physical therapy that enjoys all sports and loves the Dubs.
I will cover the anatomy, diagnosis, assessment, common symptoms, and recovery expectations with a TL;DR at the bottom!.
Anatomy
First let's define the MCL (medial collateral ligament) - The MCL is the broad fan-like ligament that provides the stability to the medial (or inside part) of your knee joint . It prevents "valgus" forces (forces pressing from the outside of the knee inward) from completely bending your knee inward.
Diagnosis
What is the difference between the grades?
Here's a nice picture explained in massive block of words below.
Grade 1: most mild injury, likely due to slight over-stretching of MCL such as with a rapid valgus movement. At WORST there are minor tears to the MCL, but again, very minimal. It is possible for this to be a contact OR non-contact injury (as with Steph). Note the valgus alignment of Steph's knee in this picture (not terribly gruesome, but if you're squeamish... maybe just leave that link blue...).
Grade 2: wide range of moderate to severe injury that includes an over-stretched MCL as well as incomplete tearing of the MCL (or a "partial tear). This is the grade is by far the hardest to predict recovery time as this depends greatly on the extent of the tear.
Grade 3: severe injury due to large valgus force at the knee that leads to a complete rupture/tear of the MCL. In a professional athlete this would likely require surgery.
Assessment
The obvious gold standard for this assessment is an MRI that would be able to show the extend of the damage to the MCL. Within an outpatient clinic or with the trainer prior to the MRI they would also conduct a series of "special tests" to check the stability of the knee ligaments and structures. Here are some of those tests that would be done:

• Lachman's test for ACL
• Anterior drawer test for ACL
• Posterior drawer test for PCL
• Varus stress test (Left) for LCL
• Valgus stress test (Right) for MCL
• McMurray's test for medial and lateral menisci

Common Symptoms
Steph would most likely experience pain. Duh. Other than this, he may have some slight instability and discomfort with any tasks that would put (here's that buzzword again) a valgus stress on his right knee. This would include pushing off from his right leg in a defensive slide, trying to maintain a right pivot foot with someone (looking at you Beverley) leaning into his leg/knee, or even happening to take the wrong jab-step with his right leg.
So why was he limping to the bus in that video o0blarson0o!?!? Well... when your knee hurts you limp. Also, when you have a ligamentous injury such as this, the knee wants to inherently be in its "loose-packed" position (the position that all the joint's surrounding ligaments are most lax) and avoid the "close-packed" position (ligaments are most taut). For the knee, loose-packed = ~25 degrees of bend (which is about where Steph was) and close-packed = full knee extension (which is what a limp avoids).
Recovery Expectation
As stated millions of times from every Reddit doctor available, MCL injuries are difficult to judge. Grade 3 is easy: out for the season (likely at least 6-8 weeks or possible surgery with appropriate rehab). Grade 2 has slightly more gray area, but still most likely out for the season (probably around the 6-8 weeks guideline, but possibly sooner). Grade 1 is tough as a lot will depend on how painful it is, how long the tissues take to heal, but can range anywhere from as little as 1 week to as long as about 6 weeks (if instability and pain remain with sharp cuts). Important to also note is that this injury possesses a definite possibility of getting worse if Steph is rushed to return to play.
Complicating Factors
A couple notes: the MCL is very closely tied into the medial meniscus and even has some connecting fibers. It is entirely possible that an MCL injury could have a slight complication of meniscus involvement, but unlikely in Steph's case. Also, there was contact with Steph's medial knee onto the court along with the valgus stretch. This would be comparable to taking a rubber band (his MCL), stretching it to maximum length (valgus stretch), putting it over the sharp corner of a table (his tibia and femur), and then hitting it with a hammer (the court). Probably not fun.
So there ya have it... A breakdown of the medical side of things...
TL;DR There's a lot of stuff goin' on in Steph's knee. It probably hurts. Possibility of it worsening if rushed, but likely back in 2-4 weeks. I'm sure he's in good hands.

The knee is a frequently injured joint, with its ligaments, menisci (a thin fibrous cartilage between the surfaces of some joints), and patellofemoral (knee) joint vulnerable to acute and repetitive use damage.
Most knee injuries require exercise training for rehabilitation, and some require surgery as well.
Predisposing factors to knee injury include the following:

1. Lower extremity malalignment (e.g. Q angle abnormalities, flat feet);
2. Limb length discrepancy;
3. Muscular imbalance and weakness.
4. Inflexibility;
5. Previous injury;
6. Inadequate proprioception;
7. Joint instability;
8. Playing surface and equipment problems; and
9. Slight predominance in females (particularly for patellofemoral problems).

Ligamentous sprains and tears are common in the knee, particularly in athletes. Because of its structure and insertion points, the anterior cruciate ligament (ACL) is more frequently injured compared with the posterior cruciate ligament (PCL). Classically, the ACL is injured when external rotation of the tibia is coupled with a valgus force on the knee (e.g. direct force from the lateral side of the knee, planting the foot and twisting the knee). Ligamentous sprains and tears are common in the knee, particularly in athletes.
The menisciare also frequently injured, particularly in athletes. The medial meniscus is more frequently torn than the lateral meniscus, due in part to its attachment to the medial collateral ligament. The menisci are poorly innervated (supplied with nerves) and relatively avascular (lack of blood vessels); thus, they are not very pain sensitive and are slow to heal following injury. The “terrible triad” is a traumatic sports injury in which the ACL, medial collateral ligament, and medial meniscus are damaged simultaneously
Patellofemoral pain syndrome is a common disorder in young athletes (particularly females) that produces anterior knee pain. Often, patellofemoral pain syndrome is caused by an off-center line of pull of the patella, which irritates the joint surfaces and retinaculum of the knee. An off-center pull of the patella can result from insufficiency muscular imbalance during knee extension and from excessive varus and valgus stresses (a deformity involving oblique displacement of part of a limb towards/away from the midline, respectively) from Q angles outside of the normal range of 13° to 18°.

Can someone with a lot of experience in C&P exams help me out this and tell me based on the notes what my rating would be? Thanks, I greatly appreciate it!
Indicate method used to obtain medical information to complete this document:

 [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information 

on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.

 [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using 

the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.

 [ ] Examination via approved video telehealth [X] In-person examination 

a. Evidence review

 Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment 

records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other:
b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No

1. Diagnosis

   a. List the claimed condition(s) that pertain to this DBQ: bilateral patellofemoral pain syndrome
   b. Select diagnoses associated with the claimed condition(s) (Check all that apply):
   [X] Patellofemoral pain syndrome Side affected: [ ] Right [ ] Left [X] Both ICD Code: M22.2x1 and M22.2x2 Date of diagnosis: Right 2012 Date of diagnosis: Left 2012
   c. Comments (if any): No response provided
   d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A
   

2. Medical history

   a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): Bilateral patellofemoral pain syndrome diagonsed in the Marines following a fall from a height when he landed on his knees. He has continued to have pain in both anterior kneessince then. He has not had care for his knees since discharge in 2013.
   b. Does the Veteran report flare-ups of the knee and/or lower leg? [ ] Yes [X] No
   c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time? [X] Yes [ ] No
   

    If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: Pain with walking, climbing or decending stairs, and with prolonged standing. He has pain with pressure on the anterior knees, so he 

   cannot kneel down.
   

3. Range of motion (ROM) and functional limitation

   a. Initial range of motion
   Right Knee
   [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)
   

    Flexion (0 to 140): 0 to 70 degrees Extension (140 to 0): 70 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: pain with flexion of the knee joint and when walking. 

   Description of pain (select best response): Pain noted on exam and causes functional loss
   If noted on exam, which ROM exhibited pain (select all that apply)? Flexion
   Is there evidence of pain with weight bearing? [X] Yes [ ] No
   Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No
   

   If yes, describe including location, severity and relationship to condition(s): pain with palpation of the patella and the anterior joint line. 

   Is there objective evidence of crepitus? [ ] Yes [X] No
   Left Knee
   [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain)
   

    Flexion (0 to 140): 0 to 70 degrees Extension (140 to 0): 70 to 0 degrees If abnormal, does the range of motion itself contribute to functional loss? [X] Yes (please explain) [ ] No If yes, please explain: pain with flexion of the knee joint and when walking. 

   Description of pain (select best response): Pain noted on exam and causes functional loss
   If noted on exam, which ROM exhibited pain (select all that apply)? Flexion
   Is there evidence of pain with weight bearing? [X] Yes [ ] No
   Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No
   

   If yes, describe including location, severity and relationship to condition(s): pain with palpation of the patella and the anterior joint line. 

   Is there objective evidence of crepitus? [ ] Yes [X] No
   b. Observed repetitive use
   Right Knee
   Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No
   Left Knee
   Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No
   c. Repeated use over time
   Right Knee
   Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No
   Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance
   

    Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Increased pain with ambulation and standing. 

   Left Knee
   Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No
   Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance
   

    Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Increased pain with ambulation and standing. 

   d. Flare-ups No response provided
   e. Additional factors contributing to disability
   Right Knee
   In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None
   Left Knee
   In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None
   

4. Muscle strength testing

   a. Muscle strength - Rate strength according to the following scale:
   0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength
   Right Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No
   Left Knee: Rate Strength: Forward flexion: 5/5 Extension: 5/5 Is there a reduction in muscle strength? [ ] Yes [X] No
   b. Does the Veteran have muscle atrophy? [ ] Yes [X] No
   c. Comments, if any: No response provided
   

5. Ankylosis

   Complete this section if the Veteran has ankylosis of the knee and/or lower leg.
   a. Indicate severity of ankylosis and side affected (check all that apply):
   Right Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis
   Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis
   b. Indicate angle of ankylosis in degrees: No response provided
   c. Comments, if any: No response provided
   

6. Joint stability tests

   a. Is there a history of recurrent subluxation?
   Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
   Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
   b. Is there a history of lateral instability?
   Right: [X] None [ ] Slight [ ] Moderate [ ] Severe
   Left: [X] None [ ] Slight [ ] Moderate [ ] Severe
   c. Is there a history of recurrent effusion?
   [ ] Yes [X] No
   d. Performance of joint stability testing
   Right Knee:
   

   Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) 

   Left Knee:
   

   Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) 

   e. Comments, if any: No response provided
   

7. Additional conditions

   a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [ ] Yes [X] No
   b. Comments, if any: No response provided
   

8. Meniscal conditions

   a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No
   b. For all checked boxes above, describe: No response provided
   

9. Surgical procedures

   No response provided
   
10. Other pertinent physical findings, complications, conditions, signs,
    

    symptoms and scars

    a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No
    b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No
    c. Comments, if any: No response provided
    

11. Assistive devices

    a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No
    b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided
    

12. Remaining effective function of the extremities

    Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)
    [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No
    

13. Diagnostic testing

    a. Have imaging studies of the knee been performed and are the results available? [X] Yes [ ] No
    

     If yes, is degenerative or traumatic arthritis documented? [ ] Yes [X] No 

    b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No
    c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided
    

14. Functional impact

    Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No
    If yes, describe the functional impact of each condition, providing one or more examples: The Veteran has significant pain in both knees with walking, standing and kneeling so that he would have a difficult time perorming duties which would require those actions.
    

15. Remarks, if any:

    No response provided