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Anterior Knee Pain
In
Adolescents
Johan Myburgh
February 2012
Anterior knee pain
• Introduction
• Case study
• Discussion
– history
– physical examination
– investigations
• Conditions
• Growing skeleton
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)
History
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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
Biomechanical evaluation
• Excessive bilateral subtalar pronation - walking
Special investigations:
X-ray - fragmentation of
the tibial tubercle with
overlying soft tissue
swelling.
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)
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.
DISCUSSION
Anterior Knee Pain
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
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.
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
Investigations
• Laboratory testing
– infection suspected - CBC, ESR, CRP
– arthritis is diagnosed - anti-CCP, ANA, RF and HLAB27 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
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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
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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)
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common cause of infrapatellar knee pain
associated with osteochondroses and PFP
Rx activity modification and biomechanical rehabilitation
Progressive eccentric strengthening is essential.
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.
KNEE
OSTEOCHONDROSES
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
OSTEOCHONDROSES
Osgood-Schlatter (OSD)
Sinding-Larsen-Johansson Syndrome
(SLJD)
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
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.
Conditions
• Osteochondritis Dissecans
– Idiopathic bone necrosis
– Acute, hemarthrosis and loose body ( locked knee)
– Most common lateral aspect of the medial femoral condyle
• Synovial plica
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–
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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
Conditions
• Bipartite patella
– superolateral patella may show an accessory ossification
centre ( pain and swelling)
• Stress fracture of the patella
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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
Conditions
• Inflammatory disorders
– Juvenile inflammatory arthritis
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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 nonpainful stimulus)
• signs of autonomic dysfunction
• special investigations are not helpful.
Conditions
• Tumors
– rare cause on anterior knee pain
– local osteosarcoma, leukemia and metastasis from
neuroblastoma
Growing skeleton
• Osteochondroses
Type
Condition
Perthe’s
disease spine
•Articular
Referred pain from the hip
and lumbar
Non-articular
Physeal
Site
Femoral head
Osteochondritis dissecans
Medial femoral condyle,
capitellum, talar dome
Osgood-Schlatter
Tibial tubercle
Sinding-Larsen-Johansson
Inferior pole patella
Sever’s lesion
Calcaneus
Sheuermann’s lesion
Thoracic spine
Blount’s lesion
Proximal tibia
• Referred pain form hip and lumber spine
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
References
• 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