2 Anterior knee pain Introduction Case study Discussion Conditions historyphysical examinationinvestigationsConditionsGrowing skeleton
3 IntroductionOne of the most common musculoskeletal complaints - pediatric populationDifferential diagnosis fairly extensive - thorough history and physical examinationSpecial attention:anatomic location of the painaggravating factorsAssessment of growth and developmentExclude hip and lumbar disorders (all patients)
4 History 15 year old male 2 month history anterior knee pain Progressively worseAggravated by activityNoticed swelling below kneeKarate – Provincial levelPain preventing exercise and tournament paticipation
5 Clinical ExaminationObservation: Swelling at the infrapatellar tendon attachment on the tibial tubercle.Palpation: Tenderness to same area.Flexibility: Hamstring tightnessNormal hip and lumbar spine examination
8 Summary (3 stage) 2. Personal. Karate is his passion - can’t imagine being not able to do it for possibly months.3. ContextualCouch 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 jumpingPhysiotherapy to correct biomechanical abnormalities and treat pain.Progression:physiotherapy and modified activity routine for 4 weeksminor relapse of symptoms 2 weeks after resuming sport specific activities, but he started his treatment regime and the pain resolved.
12 HISTORYPain 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, instabilityInflammatory symptoms – morning stiffness, swellingBleeding disordersPrevious injury & treatmentsCurrent level of functioning
13 HISTORY Overuse knee injuries - report sensation of knee instability Pseudo-giving way due to a neuromuscular inhibitionInhibition secondary to pain, muscle weakness and patellar instability.
14 Physical ExaminationComplete 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, CRParthritis is diagnosed - anti-CCP, ANA, RF and HLA-B27 for classification and treatment.Imaging studies rarely usedAssist in diagnosisPerthe’s and Slipped femoral capital epiphysisX-rays and MRI most commonly used.
16 Extensive differential diagnosis Patellofemoral pain syndromePatellofemoral instability and patellar subluxationPatellar tendinopathy (Jumper’s knee)OsteochondrosesFat pad irritation/impingementReferred pain from the hip and lumbar spineOsteochondritis DissecansSynovial plicaQuadriceps tendinopathyBipartite patellaStress fracture of the patellaBursitisInflammatory disordersPain amplification syndromesTumors
17 Patellofemoral Pain Syndrome most common cause of pediatric chronic anterior knee painetiologymalalignment of the patella relative to the femoral trochlearesult in articular cartilage damageperipatellar synovitis secondary to mechanical overloadingchemical irritation of local nerve endings
18 Patellofemoral Pain Syndrome Risk factorsmalalignment of the lower limblarger Q-anglesVMO weaknessmuscle inflexibilities like tight quadriceps, gastrocnemius, hamstrings, lateral retinaculum and IT band.Classic Hx & PxQuadriceps grinding test has a 96% sensitivity.Managementmodification of activity, flexibility and strengthening exercises, patellar tracking exercises, icing, NSAIDS, patellar taping and shoe orthotics.
19 Other patellar pathology Patellofemoral instability and patellar subluxationClinically looks like patellofemoral pain syndrome - but lateral dislocation may be elicited with palpationPatellar tendinopathy (Jumper’s knee)common cause of infrapatellar knee painassociated with osteochondroses and PFPRx activity modification and biomechanical rehabilitationProgressive eccentric strengthening is essential.
20 OSTEOCHONDROSES adolescents during growth spurt present with localized pain with activities , localized tenderness and swellingX-rays only if infection or bony tumors are suspected.Self-limiting disorders - managed conservativelyConservative 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.
21 KNEE OSTEOCHONDROSES More common PatellaSinding-Larsen-Johansson syndrome (SLJD)Osgood-SchlatterTibial TuberosityTibiaMore commoninferior attachment of patellar tendon , epiphysis of the tibial tuberclesuperior attachment ofpatellar tendon
23 Osgood-Schlatter Disease What’s new/controversial ?Journal Pediatrics July 2011Hyperosmolar Dextrose Injection for Recalcitrant Osgood-Schlatter Diseaseinjection 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 careRelease several growth factors and neuropeptides
24 Conditions Fat pad irritation/impingement Infrapatellar fat pad is a richly innervated areaImpingement occurs between the patella and femoral condyleCaused by direct trauma or a hyperextension injuryPatellar tendinopathy, PFP and synovitis can cause chronic irritation.Referred pain from the hip and lumbar spinePerthe’s disease or slipped capital femoral epiphysis may present with knee pain.
25 Conditions Osteochondritis Dissecans Synovial plica Idiopathic bone necrosisAcute, hemarthrosis and loose body ( locked knee)Most common lateral aspect of the medial femoral condyleSynovial plicaLocal synovitis caused by microtraumasynovium trapped between the patella and the femoral condyle.medial knee paina thickened band when pressed against the condyleQuadriceps tendinopathyUncommon
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 patellauncommon conditionjumping athletesintense localized pain and swellingX-ray chronic stress reaction (bone scan)BursitisPrepatellar bursa most commonly affectedInfrapatellar bursitis mimic tendinopathyAspirate bursa if septic arthritis is suspected
27 Conditions Inflammatory disorders Pain amplification syndromes Juvenile inflammatory arthritismorning stiffness and gradual resolution of the pain with activitymonoarthritisscreen for asymptomatic uveitisconfused with OSD (morning symptoms differentiate)Pain amplification syndromesReflex sympathetic dystrophy, reflex neurovascular dystrophy and complex regional pain syndromepain out of proportion with the amount of traumaunwillingness to weight bear and allodynia (pain from a non-painful stimulus)signs of autonomic dysfunctionspecial 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 spineReferred pain form hip and lumber spineTypeConditionSiteArticularPerthe’s diseaseFemoral headOsteochondritis dissecansMedial femoral condyle, capitellum, talar domeNon-articularOsgood-SchlatterTibial tubercleSinding-Larsen-JohanssonInferior pole patellaSever’s lesionCalcaneusPhysealSheuermann’s lesionThoracic spineBlount’s lesionProximal 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 affectedConditions unique to the growing skeleton like hip diseases (Perthe’s and SCFE) and osteochondrosesSystemic diseases (inflammatory disease and malignancies) should be in differential diagnosis
31 ReferencesCassas 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; 2009:593D Caine, J DiFiori, and N Maffulli. Physeal injuries in children's and youth sports: reasons for concern?, Br J Sports Med September; 40(9): 749–760Houghton KM. Review for the generalist: evaluation of anterior knee pain. Pediatric Rheumatology 2007, 5:8Gastón 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 2011Brukner and Khan Revised 3rd edition