Anterior Knee PainAnterior Knee Pain InIn AdolescentsAdolescents

Johan MyburghJohan MyburghFebruary 2012February 2012

Anterior knee painAnterior 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 ExaminationClinical 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

BiomechanicalBiomechanical evaluationevaluation

• Excessive bilateral subtalar pronation - walking

Special investigations:Special investigations:X-ray - fragmentation of the tibial tubercle with overlying soft tissue swelling.

Summary (3 stage)Summary (3 stage)

1. Clinical. Osgood-Schlatter disease– INTRINSIC FACTORS

• biomechanical abnormality• immature skeleton

– EXTRINSIC FACTORS• Kicking sport

– FITT • Overtraining ( preparing for tournament)

Summary (3 stage)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.

ProblemProblem listlist

• Active - Osgood-Schlatter disease

• Passive - Excessive bilateral subtalar overpronation

ManagementManagement planplan • Conservative

1. Regular icing of the area.2. Modifying activities - No pain causing activities

like jumping3. 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 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 ExaminationPhysical 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 diagnosisExtensive 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 SyndromePatellofemoral 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 SyndromePatellofemoral 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 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 KNEE OSTEOCHONDROSESOSTEOCHONDROSES

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

OSTEOCHONDROSESOSTEOCHONDROSES

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

Osgood-Schlatter DiseaseOsgood-Schlatter Disease

• What’s new/controversial ?Journal Pediatrics July 2011Hyperosmolar 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 skeletonGrowing 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

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): 1014-22.• Patel DR. Musculoskeletal injuries in sports. Prim Care. Jun 2006;

33(2): 545-79. • 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. 2006 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

Thank you