Patient with a painful knee post-left anterior cruciate ligament (ACL) reconstruction and medial meniscectomy. Single photon emission CT (SPECT)-CT dual phase knees, delayed phase whole-body and SPECT CT show that the epicentre of focal metabolic activity localises to the medial tibial spine and extends posteriorly along the medial aspect of the intercondylar notch. In addition, there is a moderately increased circumferential uptake associated with the medial tibial plateau. Both regions demonstrate degenerative changes as manifested by subchondral sclerosis, cortical irregularity, joint space loss and osteophytosis on CT. The focal hyperaemic uptake, very close to the intercondylar notch of the attachment of the ACL, is suggestive of possible disease related to the ACL reconstruction on a background of active degenerative changes and osteophyte fragmentation.