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Anterior Knee Pain In Adolescents Johan Myburgh February 2012.

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Presentation on theme: "Anterior Knee Pain In Adolescents Johan Myburgh February 2012."— Presentation transcript:

1 Anterior Knee Pain In Adolescents Johan Myburgh February 2012

2 Anterior knee pain Introduction Case study Discussion Conditions
history physical examination investigations Conditions Growing skeleton

3 Introduction One of the most common musculoskeletal complaints - pediatric population Differential diagnosis fairly extensive - thorough history and physical examination Special attention: anatomic location of the pain aggravating factors Assessment of growth and development Exclude hip and lumbar disorders (all patients)

4 History 15 year old male 2 month history anterior knee pain
Progressively worse Aggravated by activity Noticed swelling below knee Karate – Provincial level Pain preventing exercise and tournament paticipation

5 Clinical Examination Observation: Swelling at the infrapatellar tendon attachment on the tibial tubercle. Palpation: Tenderness to same area. Flexibility: Hamstring tightness Normal hip and lumbar spine examination

6 Biomechanical evaluation
Excessive bilateral subtalar pronation - walking Special investigations: X-ray - fragmentation of the tibial tubercle with overlying soft tissue swelling.

7 Summary (3 stage) Clinical. Osgood-Schlatter disease INTRINSIC FACTORS
biomechanical abnormality immature skeleton EXTRINSIC FACTORS Kicking sport FITT Overtraining ( preparing for tournament)

8 Summary (3 stage) 2. Personal.
Karate is his passion - can’t imagine being not able to do it for possibly months. 3. Contextual Couch will not understand the chronic nature of his condition.

9 Problem list Active - Osgood-Schlatter disease
Passive - Excessive bilateral subtalar overpronation

10 Management plan Conservative Progression: Regular icing of the area.
Modifying activities - No pain causing activities like jumping Physiotherapy to correct biomechanical abnormalities and treat pain. Progression: physiotherapy and modified activity routine for 4 weeks minor relapse of symptoms 2 weeks after resuming sport specific activities, but he started his treatment regime and the pain resolved.

11 DISCUSSION Anterior Knee Pain

12 HISTORY Pain characteristics – location, character, onset, duration, change with activity or rest, aggravating and alleviating factors, and night pain. Trauma – acute major trauma, repetitive minor trauma. Mechanical symptoms – locking or extension block, instability Inflammatory symptoms – morning stiffness, swelling Bleeding disorders Previous injury & treatments Current level of functioning

13 HISTORY Overuse knee injuries - report sensation of knee instability
Pseudo-giving way due to a neuromuscular inhibition Inhibition secondary to pain, muscle weakness and patellar instability.

14 Physical Examination Complete knee examination (above and below joints) Examine - contralateral knee and the ipsilateral hip joint. Biomechanical examination - predisposing factors. Genetic predisposition includes excessive stiffness, loose-jointedness and poor muscle tone. Knee joint swelling - suspicion of intra-articular pathology, synovitis

15 Investigations Laboratory testing Imaging studies rarely used
infection suspected - CBC, ESR, CRP arthritis is diagnosed - anti-CCP, ANA, RF and HLA-B27 for classification and treatment. Imaging studies rarely used Assist in diagnosis Perthe’s and Slipped femoral capital epiphysis X-rays and MRI most commonly used.

16 Extensive differential diagnosis
Patellofemoral pain syndrome Patellofemoral instability and patellar subluxation Patellar tendinopathy (Jumper’s knee) Osteochondroses Fat pad irritation/impingement Referred pain from the hip and lumbar spine Osteochondritis Dissecans Synovial plica Quadriceps tendinopathy Bipartite patella Stress fracture of the patella Bursitis Inflammatory disorders Pain amplification syndromes Tumors

17 Patellofemoral Pain Syndrome
most common cause of pediatric chronic anterior knee pain etiology malalignment of the patella relative to the femoral trochlea result in articular cartilage damage peripatellar synovitis secondary to mechanical overloading chemical irritation of local nerve endings

18 Patellofemoral Pain Syndrome
Risk factors malalignment of the lower limb larger Q-angles VMO weakness muscle inflexibilities like tight quadriceps, gastrocnemius, hamstrings, lateral retinaculum and IT band. Classic Hx & Px Quadriceps grinding test has a 96% sensitivity. Management modification of activity, flexibility and strengthening exercises, patellar tracking exercises, icing, NSAIDS, patellar taping and shoe orthotics.

19 Other patellar pathology
Patellofemoral instability and patellar subluxation Clinically looks like patellofemoral pain syndrome - but lateral dislocation may be elicited with palpation Patellar tendinopathy (Jumper’s knee) common cause of infrapatellar knee pain associated with osteochondroses and PFP Rx activity modification and biomechanical rehabilitation Progressive eccentric strengthening is essential.

20 OSTEOCHONDROSES adolescents during growth spurt
present with localized pain with activities , localized tenderness and swelling X-rays only if infection or bony tumors are suspected. Self-limiting disorders - managed conservatively Conservative management includes activity modification, biomechanical rehabilitation, icing, NSAIDS, muscle strengthening and muscle flexibility exercises. can last ≤ 24 months until skeleton matures. symptoms persist past skeletal maturity surgery indicated to excise the separated tibial tuberosity fragment.

Patella Sinding-Larsen-Johansson syndrome (SLJD) Osgood-Schlatter Tibial Tuberosity Tibia More common inferior attachment of patellar tendon , epiphysis of the tibial tubercle superior attachment of patellar tendon

22 OSTEOCHONDROSES Osgood-Schlatter (OSD)
Sinding-Larsen-Johansson Syndrome (SLJD)

23 Osgood-Schlatter Disease
What’s new/controversial ? Journal Pediatrics July 2011 Hyperosmolar Dextrose Injection for Recalcitrant Osgood-Schlatter Disease injection of the patellar tendon enthesis/tibial apophysis with 12.5% dextrose (monthly x 3) better 3,6,12 month outcome in pain score (NPPS—Nirschl Pain Phase Scale) than usual care Release several growth factors and neuropeptides

24 Conditions Fat pad irritation/impingement
Infrapatellar fat pad is a richly innervated area Impingement occurs between the patella and femoral condyle Caused by direct trauma or a hyperextension injury Patellar tendinopathy, PFP and synovitis can cause chronic irritation. Referred pain from the hip and lumbar spine Perthe’s disease or slipped capital femoral epiphysis may present with knee pain.

25 Conditions Osteochondritis Dissecans Synovial plica
Idiopathic bone necrosis Acute, hemarthrosis and loose body ( locked knee) Most common lateral aspect of the medial femoral condyle Synovial plica Local synovitis caused by microtrauma synovium trapped between the patella and the femoral condyle. medial knee pain a thickened band when pressed against the condyle Quadriceps tendinopathy Uncommon

26 Conditions Bipartite patella Stress fracture of the patella Bursitis
superolateral patella may show an accessory ossification centre ( pain and swelling) Stress fracture of the patella uncommon condition jumping athletes intense localized pain and swelling X-ray chronic stress reaction (bone scan) Bursitis Prepatellar bursa most commonly affected Infrapatellar bursitis mimic tendinopathy Aspirate bursa if septic arthritis is suspected

27 Conditions Inflammatory disorders Pain amplification syndromes
Juvenile inflammatory arthritis morning stiffness and gradual resolution of the pain with activity monoarthritis screen for asymptomatic uveitis confused with OSD (morning symptoms differentiate) Pain amplification syndromes Reflex sympathetic dystrophy, reflex neurovascular dystrophy and complex regional pain syndrome pain out of proportion with the amount of trauma unwillingness to weight bear and allodynia (pain from a non-painful stimulus) signs of autonomic dysfunction special investigations are not helpful.

28 Conditions Tumors rare cause on anterior knee pain
local osteosarcoma, leukemia and metastasis from neuroblastoma

29 Growing skeleton Osteochondroses
Referred pain from the hip and lumbar spine Referred pain form hip and lumber spine Type Condition Site Articular Perthe’s disease Femoral head Osteochondritis dissecans Medial femoral condyle, capitellum, talar dome Non-articular Osgood-Schlatter Tibial tubercle Sinding-Larsen-Johansson Inferior pole patella Sever’s lesion Calcaneus Physeal Sheuermann’s lesion Thoracic spine Blount’s lesion Proximal tibia

30 Conclusion Anterior knee pain - common in the pediatric population
Thorough history and physical examination necessary, often enough to make an accurate diagnosis. Patellofemoral joint and the extensor mechanism of the knee - most common areas affected Conditions unique to the growing skeleton like hip diseases (Perthe’s and SCFE) and osteochondroses Systemic diseases (inflammatory disease and malignancies) should be in differential diagnosis

31 References Cassas KJ. Childhood and adolescent sports-related overuse injuries. Am Fam Physician. Mar 2006; 73(6): Patel DR. Musculoskeletal injuries in sports. Prim Care. Jun 2006; 33(2):   Mercier LR. Osgood-Schlatter disease. Ferri’s Clinical Advisor: Instant Diagnosis and Treatment. 9th ed. St. Louis, Mo: Mosby; 2009:593 D Caine, J DiFiori, and N Maffulli. Physeal injuries in children's and youth sports: reasons for concern?, Br J Sports Med September; 40(9): 749–760 Houghton KM. Review for the generalist: evaluation of anterior knee pain. Pediatric Rheumatology 2007, 5:8 Gastón Andrés Topol, MD, Leandro ArielPodesta, MD, Kenneth Dean Reeves, MD, Marcelo Francisco Raya, PT, Bradley Dean Fullerton, MD,and Hung-wen Yeh, PhD: Journal Pediatrics July 2011 Brukner and Khan Revised 3rd edition

32 Thank you

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