Pediatric Painful KneePediatric Painful Knee

Emily C Dawson MD PL2Emily C Dawson MD PL2

December 19, 2005December 19, 2005

Estimated 30 million children participate Estimated 30 million children participate in organized sports each yearin organized sports each year

Pediatricians now primary medical Pediatricians now primary medical resource for these active childrenresource for these active children

Sports are responsible forSports are responsible for > 10 million PCP visits each year – sports > 10 million PCP visits each year – sports

and overexertion leading causeand overexertion leading cause > 35% all medically attended injuries 5-17y> 35% all medically attended injuries 5-17y > 20% ED visits 5-24y> 20% ED visits 5-24y

Musculoskeletal injuries are 2Musculoskeletal injuries are 2ndnd most most common reason for visits to ED/PCPcommon reason for visits to ED/PCP

Pediatric Residency Education: Is Sports Pediatric Residency Education: Is Sports Medicine Getting Its Fair Share? Medicine Getting Its Fair Share? PediatricsPediatrics Jan 2005Jan 2005 US pediatric residency SM curricula, teaching US pediatric residency SM curricula, teaching

methods and resident evaluation of SM methods and resident evaluation of SM educationeducation

Chief residents and PL3 randomly selected from Chief residents and PL3 randomly selected from 100 US ACGME accredited residency programs100 US ACGME accredited residency programs

Almost 1/3 program did not include Almost 1/3 program did not include musculoskeletal exam teaching in their musculoskeletal exam teaching in their curriculumscurriculums

PL3 rated teaching of the joint exam and the PL3 rated teaching of the joint exam and the preparticipation physical as most poorly taught preparticipation physical as most poorly taught components of physical examcomponents of physical exam

Pediatric Residents’ Knowledge and Skill in Pediatric Residents’ Knowledge and Skill in Performing Physical Examinations of the Performing Physical Examinations of the Ankle and Knee. Ankle and Knee. Pediatrics April 2001Pediatrics April 2001 Objective Structures Clinical Examination Objective Structures Clinical Examination

(OSCE) (OSCE) used to evaluate competency in used to evaluate competency in assessing clinical problems – assessing clinical problems – howeverhowever OSCE OSCE involving musculoskeletal exam not publishedinvolving musculoskeletal exam not published

Developed method for evaluating skill and Developed method for evaluating skill and knowledge of PE knee/ankle and reliabilityknowledge of PE knee/ankle and reliability

Watched video, observed an attending and Watched video, observed an attending and demonstrated correct technique by residentdemonstrated correct technique by resident

Written and clinical evaluation at begin Written and clinical evaluation at begin rotation, end of rotation and 9 months later – rotation, end of rotation and 9 months later – suboptimal at baseline and improved suboptimal at baseline and improved significantly after teaching interventionsignificantly after teaching intervention

Case #1Case #1

13 y/o junior high track star complains of 13 y/o junior high track star complains of intermittent left anterior knee pain. He intermittent left anterior knee pain. He denies any trauma to the knee. He tried to denies any trauma to the knee. He tried to ease off training between track events, but ease off training between track events, but the discomfort returned quickly. He has the discomfort returned quickly. He has grown 4 inches in the past year.grown 4 inches in the past year.

Case #2Case #2

18 y/o female runner presents recurrent bilateral knee pain. She says over the last year her knees have been an intermittent source of discomfort. After running her knees ache for 1 hour then gradually improve. She also noticed that she has pain when walking down the stairs and rising from a seated position.

Case #3Case #3

17 y/o female soccer player presents to ED with a right knee that gave way and was unsteady. She was reaching up in hyperextension to play a ball and she felt a pop in her right knee. There was immediate swelling and she was carried off the field.

Case #4Case #4

16 y/o AAM was evaluated at clinic 6 days after sustaining an acute injury to his right knee while playing baseball. He had acute onset of R knee pain after striking out at bat. He heard a single clunk in his knee and noticed immediate pain and swelling. He was seen at a local ED and placed in a knee immobilizer and told to follow up with sports medicine. He noticed that the knee "gave out" on him several times since the accident.

Anatomy of Knee JointAnatomy of Knee Joint

Anatomy of Knee JointAnatomy of Knee Joint

Anatomy of Knee JointAnatomy of Knee Joint

Evaluation of the KneeEvaluation of the Knee

Mechanism of InjuryMechanism of Injury Observation and ComparisonObservation and Comparison

Standing/WalkingStanding/Walking Genu varum/valgum/recurvatumGenu varum/valgum/recurvatum

PalpationPalpation BonesBones Soft TissueSoft Tissue

Active and Passive ROMActive and Passive ROM Flexion 135 -140Flexion 135 -140°° Extension 0°Extension 0° Internal Rotation 10°Internal Rotation 10° External Rotation 10°External Rotation 10°

Evaluation of the KneeEvaluation of the Knee

Stress TestsStress Tests Valgus/VarusValgus/Varus Anterior DrawerAnterior Drawer Posterior DrawerPosterior Drawer LachmansLachmans McMurrayMcMurray Apprehension Apprehension

Manual Muscle TestingManual Muscle Testing HamstringsHamstrings QuadricepsQuadriceps Internal RotatorInternal Rotator External RotatorsExternal Rotators

Evaluation of the KneeEvaluation of the Knee Neurological TestingNeurological Testing

SensorySensory MotorMotor Deep Tendon ReflexesDeep Tendon Reflexes

CirculatoryCirculatory Functional TestsFunctional Tests

Straighten and bend kneeStraighten and bend knee StandStand Deep knee bendDeep knee bend Pivot on planted legPivot on planted leg JogJog ZigzagZigzag CuttingCutting RunningRunning Single leg HopSingle leg Hop

ObservationObservation

PalpationPalpation

Valgus/Varus Stress TestValgus/Varus Stress Test

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Valgus Stress TestValgus Stress Test

Varus Stress TestVarus Stress Test

Anterior Drawer TestAnterior Drawer Test

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Anterior Drawer TestAnterior Drawer Test

Posterior Drawer TestPosterior Drawer Test

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Posterior Drawer TestPosterior Drawer Test

Lachman TestLachman Test

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Lachman TestLachman Test

McMurray TestMcMurray Test

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McMurray TestMcMurray Test

Patellar CompressionPatellar Compression

Patellar Grind TestPatellar Grind Test

Patellar ApprehensionPatellar Apprehension

AlignmentAlignment

Case #1Case #1

13 y/o junior high track star complains of 13 y/o junior high track star complains of intermittent left anterior knee pain. He intermittent left anterior knee pain. He denies any trauma to the knee. He tried to denies any trauma to the knee. He tried to ease off training between track events, but ease off training between track events, but the discomfort returned quickly. He has the discomfort returned quickly. He has grown 4 inches in the past year.grown 4 inches in the past year.

Osgood SchlatterOsgood Schlatter

Anterior knee pain, gradually increases over time – Anterior knee pain, gradually increases over time – running, jumping, kneelingrunning, jumping, kneeling

Active adolescents (13-14y boy/11-12y girl), recent Active adolescents (13-14y boy/11-12y girl), recent growth spurtgrowth spurt

Apophysitis of proximal tibial tuberosity at insertion of Apophysitis of proximal tibial tuberosity at insertion of patellar tendon – avulsion of developing ossification patellar tendon – avulsion of developing ossification centercenter

PE: localized tenderness, soft tissue swelling – tibial PE: localized tenderness, soft tissue swelling – tibial tuberosity, reproducible pain with extension of knee tuberosity, reproducible pain with extension of knee against resistance, squattingagainst resistance, squatting

Benign, self limited, resolves 6-18monthsBenign, self limited, resolves 6-18months Imaging: not needed, clinical correlationImaging: not needed, clinical correlation Tx: strengthen quads, stretching quads and Tx: strengthen quads, stretching quads and

hamstrings, protective pad, ice and NSAIDShamstrings, protective pad, ice and NSAIDS

Osgood SchlatterOsgood Schlatter

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Case #2Case #2

18 y/o female runner presents recurrent bilateral knee pain. She says over the last year her knees have been an intermittent source of discomfort. After running her knees ache for 1 hour then gradually improve. She also noticed that she has pain when walking down the stairs and rising from a seated position.

Patellar Grind TestPatellar Grind Test

Patellar CompressionPatellar Compression

AlignmentAlignment

Patellofemoral SyndromePatellofemoral Syndrome Overuse and overloadOveruse and overload Retropatellar or peripatellar pain – physical and biomechanical Retropatellar or peripatellar pain – physical and biomechanical

changes in PF jointchanges in PF joint Chronic anterior knee pain – during activity, descending steps, Chronic anterior knee pain – during activity, descending steps,

rising from seated positionrising from seated position Patella articulates in femoral groove – moves up/down, tilts and Patella articulates in femoral groove – moves up/down, tilts and

rotates rotates → various points of contact→ various points of contact Many factors that effect stabilizationMany factors that effect stabilization

Flat feet (pronation) or High archesFlat feet (pronation) or High arches Increased Q angle Increased Q angle Muscular weaknessMuscular weakness Decreased flexibilityDecreased flexibility

PE: pronation, flattened arch, patellas facing inward, PE: pronation, flattened arch, patellas facing inward, underdevelopment VMO, +patellar grind, + underdevelopment VMO, +patellar grind, + compressioncompression

Imaging: AP. Lat and sunrise (axial) xraysImaging: AP. Lat and sunrise (axial) xrays Tx: Rest, quad strengthening, stretching,evaluation of footwear, Tx: Rest, quad strengthening, stretching,evaluation of footwear,

ice and NSAIDSice and NSAIDS

Case #3Case #3

17 y/o female soccer player presents to ED with a right knee that gave way and was unsteady. She was reaching up in hyperextension to play a ball and she felt a pop in her right knee. There was immediate swelling and she was carried off the field.

Anterior Drawer TestAnterior Drawer Test

Lachman TestLachman Test

ACL InjuryACL Injury

Direct trauma, landing off-balance or cutting Direct trauma, landing off-balance or cutting Twisting or hyperextension when foot is planted and Twisting or hyperextension when foot is planted and

the knee extended the knee extended Often accompanied by other injuries - MCL and Often accompanied by other injuries - MCL and

menisci menisci PE: acute hemarthrosis, + anterior drawer, + PE: acute hemarthrosis, + anterior drawer, +

LachmansLachmans Imaging: MRIImaging: MRI Tx: nonsurgical vs surgicalTx: nonsurgical vs surgical

Physical therapy and bracing – 6 monthsPhysical therapy and bracing – 6 months ACL reconstructionACL reconstruction

ACL TearACL Tear

Patellar ApprehensionPatellar Apprehension

Case #4Case #4

16 y/o AAM was evaluated at clinic 6 days after sustaining an acute injury to his right knee while playing baseball. He had acute onset of R knee pain after striking out at bat. He heard a single clunk in his knee and noticed immediate pain and swelling. He was seen at a local ED and placed in a knee immobilizer and told to follow up with sports medicine. He noticed that the knee "gave out" on him several times since the accident.

Patellar Patellar Dislocation/SubluxationDislocation/Subluxation

Twisting movement about the knee or traumaTwisting movement about the knee or trauma Almost always dislocates laterallyAlmost always dislocates laterally Teens, girls> boysTeens, girls> boys Predisposition – weak VMO, patella alta, knock kneed, Predisposition – weak VMO, patella alta, knock kneed,

joint laxity or hypermobilityjoint laxity or hypermobility PE: lateral patella, 20-30PE: lateral patella, 20-30° flexion, swelling, ° flexion, swelling, + +

apprehension test, medial joint line tenderness, pain apprehension test, medial joint line tenderness, pain with valgus stresswith valgus stress

Imaging: pre/post reduction films (AP, lat & axial), MRIImaging: pre/post reduction films (AP, lat & axial), MRI Tx: Reduction – supine, hips flexed, extend knee while Tx: Reduction – supine, hips flexed, extend knee while

apply medial pressure to lateral side of patella. apply medial pressure to lateral side of patella. Immobilize, compression, elevation, ice and NSAIDS. Immobilize, compression, elevation, ice and NSAIDS. PT – ROM, decrease swelling, strengthen quads. PT – ROM, decrease swelling, strengthen quads.

Patellar DislocationPatellar Dislocation

References:

Beasley L, Vidal AF. Traumatic patellar dislocation in children and adolescents: treatment update and literature review. Current Opinion in Pediatrics. 2004; 16: p29-36

Demorest R et al. Pediatric Residency Education: Is Sports Medicine Getting Its Fair Share. Pediatrics. January 2005: p28-33

Hergenroeder A. Causes of Knee Pain and Injury in the Young Athlete. www.uptodate.com

Hergenroeder et al. Pediatric Residents’ Performance of Ankle and Knee Examination after Educational Intervention. Pediatrics. April 2001

Hergenroeder et al. Development and Evaluation of a Method for Evaluating Pediatric Residents’ Knowledge and Skill in Performing Physical Examinations of the Ankle and Knee. Pediatrics. April 2001

Juhn M. Patellofemoral Pain Syndrome: A Review and Guidelines for Treatment. American Family Physician. November 1999: p2012-2018

Kienstra A, Macias C. Osgood-Schlatter Disease. www.uptodate.com.