A 40-year-old male presented with acute right knee pain and frequent falls over the past week without a history of trauma. Examination found reduced right knee reflex but no other abnormalities. MRI revealed an L3-L4 disc extrusion. Though the patient's pain was in the knee, the neurological exam suggested radiculopathy and MRI confirmed lumbar disc disease, demonstrating that knee pain can originate from the spine. Conservative treatment was recommended given minimal deficits and low risk of progression.

1. A case of Knee buckling
disc extrusion L3 – L4
Vinod Naneria
Girish Yeotikar
Arjun Wadhwani
Choithram Hospital & Research Centre,
Indore India

2. Case summary
• A 40 years old male C/o acute pain in the right
knee associated with frequent fall since last 7
days.
• No history of trauma.
• He was scared to walk with out support.
• Patient was limping and had insecurity while
walking.
• Now pain was gradually reducing.

3. Clinical examination
• Right knee was cold, (no inflammation)
• no deformity,
• no effusion,
• no tenderness,
• no laxity and had full range of movements.
• Patello-femoral joint was normal.

4. Clinical examination
• Examination of hip:
• full range free movements.
• Spine full flexion,
• SLRT - negative.
• Ankle normal with palpable DP, & PT vessels.
• EHL gr 5 power,
• ankle jerks are normal on both sides.
• Unable to walk on toes and heels.

5. Clinical examination
• There was no wasting of any muscle.
• The history was only 7 days.
• Active quadriceps was ok but not against
resistance (could be attributed due to pain).
• Quadriceps weakness gr 3 ?
• Left knee jerk was present.
• Right knee jerk was absent.

6. Clinical examination
• Testing of knee reflex and comparing with
deep reflexes of other limb, click the
possibility of neurological involvement.
• Hence I asked for MRI. My patient had doubt
in mind. His pain/discomfort was in/around
knee and I am asking for MRI of spine!

9. Treatment
• Conservative
– Pain was getting less.
– Mono-radiculopathy.
– Minimal neurological deficit.
– Least possibility of progression/or deterioration
of neurology.

12. comments
• L3 –L4 extruded disc can be missed.
• Knee pain can come from spine and hip.
• High degree of suspicion.
• Through neurological examination.
• Comparison on two sides.

13. comments
• When Patient’s narration of symptoms does
not match with the clinical examination, it is
better to over investigate the patient.
• When differentiating between an L3
radiculopathy versus a femoral neuropathy,
weakness in the hip adductors in addition to
the quadriceps group would indicate an L3
radiculopathy.

14. DISCLAIMER
• Information contained and transmitted by this presentation is based
on personal experience and collection of cases at Choithram Hospital
& Research centre, Indore, India.
• It is intended for use only by the students of orthopaedic surgery.
• Views and opinion expressed in this presentation are personal.
• Depending upon the x-rays and clinical presentations viewers can
make their own opinion.
• For any confusion please contact the sole author for clarification.
• Every body is allowed to copy or download and use the material best
suited to him.
• We not responsible for any controversies arise out of this
presentation. For any correction or suggestion please contact
naneria@yahoo.com