Presentation on theme: "Anterior Knee Pain In In Adolescents Adolescents Anterior Knee Pain In In Adolescents Adolescents Johan Myburgh February 2012 Johan Myburgh February 2012."— Presentation transcript:
Anterior Knee Pain In In Adolescents Adolescents Anterior Knee Pain In In Adolescents Adolescents Johan Myburgh February 2012 Johan Myburgh February 2012
Anterior knee pain Introduction Case study Discussion – history – physical examination – investigations Conditions Growing skeleton
IntroductionIntroduction 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)
HistoryHistory 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
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
Biomechanicalevaluation Biomechanical evaluation Excessive bilateral subtalar pronation - walking Special investigations: X-ray - fragmentation of the tibial tubercle with overlying soft tissue swelling.
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.
Problem list Active - Osgood-Schlatter disease Passive - Excessive bilateral subtalar overpronation
Management plan Conservative 1.Regular icing of the area. 2.Modifying activities - No pain causing activities like jumping 3.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.
DISCUSSIONDISCUSSION Anterior Knee Pain
HISTORYHISTORY 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
HISTORYHISTORY 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.
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
InvestigationsInvestigations Laboratory testing – 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.
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
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
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.
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.
OSTEOCHONDROSESOSTEOCHONDROSES 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.
KNEE OSTEOCHONDROSES Patella Sinding-Larsen-Johansson syndrome (SLJD) Tibial Tuberosity Tibia Osgood-Schlatter More common inferior attachment of patellar tendon, epiphysis of the tibial tubercle superior attachment of patellar tendon
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
ConditionsConditions 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.
ConditionsConditions Osteochondritis Dissecans – 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
ConditionsConditions Bipartite patella – 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
ConditionsConditions Inflammatory disorders – 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.
ConditionsConditions Tumors – rare cause on anterior knee pain – local osteosarcoma, leukemia and metastasis from neuroblastoma
Growing skeleton Osteochondroses Referred pain from the hip and lumbar spine Referred pain form hip and lumber spine TypeConditionSite ArticularPerthe’s diseaseFemoral head Osteochondritis dissecansMedial femoral condyle, capitellum, talar dome Non-articularOsgood-SchlatterTibial tubercle Sinding-Larsen-Johansson Inferior pole patella Sever’s lesionCalcaneus PhysealSheuermann’s lesionThoracic spine Blount’s lesionProximal tibia
ConclusionConclusion 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
ReferencesReferences 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 3 rd edition