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Adolescent Knee Pain Management Gregory A FEATURE Adolescent Knee Pain Management Gregory A. Schmale, MD he child or adolescent who referred to a pediatric and adolescent presents with a painful knee sports medicine specialist. T is a routine challenge for most Injuries to the knee occurred with primary care providers. Knee pain is an incidence of nearly one per player one of the most common reasons for per year in a survey of English teen- referral from our local primary care age soccer players,1 and the prevalence providers to the orthopedic and sports of diffuse anterior knee pain has been medicine specialist. Complaints may reported in up to 40% of adolescents be acute or long-standing, and making participating in sports.2 Common acute a diagnosis that responds to treatment knee injuries and chronic knee condi- for the patient with long-standing knee tions that present in youth can be found pain may be elusive. Careful consid- in Table 1 (see page 123) eration of the history, physical exam findings, and imaging study results can IMPORTANCE OF help sort through which patients can HISTORY IN MEDICAL EXAM be managed in the primary care pro- Complaints of knee pain are typi- vider’s office and which ones should be cally either acute or chronic. A patient with a recent injury may be particularly Gregory A. Schmale, MD, is Director, Orthope- difficult to work-up: the history of the dic Medical Education and Local Program Direc- event may be fresh in the patient’s mind tor, Orthopedics Residency at Seattle Children’s and the pain that resulted may still lin- Hospital; and Associate Professor, Department ger, leading to a nervous, tense, and of Orthopaedics and Sports Medicine, University difficult-to-examine patient, depending of Washington School of Medicine. on the level of their discomfort. Address correspondence to: Gregory A. A history of swelling suggests inju- Schmale, MD, Department of Orthopedics and Sports Medicine, 4800 Sand Point Way NE, Se- ry within the joint. In the acute setting, attle, WA 98105; email: Gregory.schmale@seattle- swelling likely represents a hemarthro- childrens.org. sis, or blood in the joint from trauma. Disclosure: The author has no relevant finan- An anterior cruciate ligament (ACL) cial relationships to disclose. tear, physeal or osteochondral fracture, doi: 10.3928/00904481-20130222-12 patella dislocation, or meniscus tear © Shutterstock 122 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:3 | MARCH 2013 FEATURE can all produce a hemarthrosis.3,4 In TABLE 1. patients with chronic swelling, the ef- fusion may be indicative of an inflam- Common Causes of Knee Pain in Youth matory arthritis. Acute Injuries Semi-Acute Conditions Chronic Conditions Most people have joints that “pop,” Fracture (femur/tibia/patella) Osteochondritis dissecans Inflammatory arthritis likely reflecting soft tissues snapping Dislocation (patella) Slipped capital femoral Apophysitis: benignly over bony prominences. The epiphysis Osgood-Schlatter “cracking of knuckles” type of joint pop- Sinding-Larsen-Johansson ping is believed to be a benign process, resulting from a cavitation phenomenon Meniscus tear (torn discoid Loose body Anterior knee pain: meniscus) Patello-femoral syndrome where sudden volumetric changes in the Impinging Hoffa’s fat pad joint space are accompanied by popping Anterior cruciate ligament Tumor Tendonitis: as carbon dioxide moves out of solu- (ACL) tear Quadriceps 5 tion from the dissolved state. Joints Patellar tendon that “clunk” or “snap,” with a jump of Medial collateral ligament Infection the patella or the tibia during knee flex- (MCL) tear ion or extension, suggest a mechanical Soft tissue contusion problem (see Table 2, page 124). Joints that lock or catch suggest a meniscal pathology or a loose body in the knee. The notion of “giving way” is establishes a baseline for comparison coloration can be done without touch- a difficult symptom to interpret. Quad- and can potentially reassure the patient ing the injured knee. Gently palpating riceps inhibition, or the cessation of of the examiner’s gentle approach. On the joint line and the physes, the tibial quadriceps contraction when a patient the other hand, starting on the unin- tubercle and the inferior border of the experiences pain can produce “giv- jured side with an aggressive, forceful, patella helps identify the location and ing way”; so too does a subluxating and rapid exam may only heighten the normal prominences of these land- or dislocating patella, or a knee with patient’s apprehension. A complaint of marks. Flexing the knee somewhat may major ligament injury. Distinguishing knee pain may reflect irritation of the help the examiner locate the joint line, between these different causes can be obturator nerve from a hip pathology, as it lies both medial and lateral to the difficult. Recreating the apprehensive so examination of the hips should be in- inferior border of the patella when the feeling in the patient during the exam cluded when the patient is supine. Log knee is flexed. Tests of stability (de- by using specific maneuvers can help rolling the limb on the unaffected side, scribed below), and gentle provocation confirm a diagnosis. followed by gentle hip flexion to 90 de- of the uninjured knee will give the ex- grees, then internal and external rotation aminer a sense of baseline tightness or STAGES OF FULL of the hip in flexion will establish the laxity of the knee. PHYSICAL EXAM norm for comparison. On the injured On the injured side, gently palpat- For patients who are uncomfort- side, pain with log rolling while holding ing the landmarks described above may able and/or apprehensive, I recommend the knee still may suggest a hip pathol- help establish the point of maximal limiting the exam of the injured knee. ogy. If flexing the hip results in obligate tenderness (PMT), though patient dis- However, I do try to gain as much in- external rotation and abduction, that comfort may make identification of the formation as possible from the visit. suggests hip pathology such as slipped PMT impossible. The PMT is a valu- Are there crutches in the room? Even capital femoral epiphysis (SCFE). able landmark in identifying the site if there are crutches present, I’ll ask the of injury or pathology in the child and patient to try to take a few steps without LIMITED EXAM OF THE adolescent’s knee.6 Mild flexion, if tol- them, if they think they can. Watching ACUTELY INJURED KNEE erated, followed by stability testing can the patient walk may help in identifica- After examining the hips, the unin- be useful. However, I am quick to wrap- tion of the source of their discomfort, jured knee is observed palpated, gen- up the exam of the acutely injured knee potentially suggesting hip as opposed to tly ranged, and provoked to establish a and order orthogonal radiographs (AP knee pathology. baseline. Comparing the two knees with and lateral, supine) if there is marked Examining the uninjured side first regards to size, resting position, and swelling, ecchymosis, gross instability, PEDIATRIC ANNALS 42:3 | MARCH 2013 Healio.com/Pediatrics | 123 FEATURE or refusal to ambulate. Worth noting, the TABLE 2. Ottawa knee rules have been validated in children, having a 100% sensitivity for Common symptoms and signs of various acute knee injuries identification of fracture in patients ages 2 to 16 years. The Ottawa criteria for ra- Injury Symptoms Signs diographs of the acutely injured knee in- Soft tissue Diffuse pain Local swelling without effusion clude: 1) tenderness at head of fibula; 2) contusion Painful walking Resolving ecchymosis isolated tenderness of patella (no bone Bruising tenderness of knee other than patella); ACL/MCL sprain Wobbly knee — instability Unstable ligament exam 3) inability to flex to 90 degrees; and 4) Swelling after activity Palpable effusion inability to bear weight immediately and Meniscus tear Sudden onset loss of motion in the emergency department (defined as Intermittent clunking or snapping an inability to transfer weight twice onto each lower limb, regardless of limping).7 Patellar Weakness Tender medial knee dislocation Intermittent “giving way” Apprehension with lateral push to Prescribing a hinged knee brace that patella when gently flexing from is left open enough to allow a tolerable full extension range of motion and crutches as needed Loose body Intermittent locking or pinching Palpable mobile body for comfort, along with the encourage- Feels like something may be loose Variable range of motion ment to remove the brace and gently and “floating” around in the joint move the knee when resting is often the Fracture Inability to weight bear Ecchymosis best approach to the patient with a pain- Physeal tenderness ful and acutely injured knee. Rest, ice, Tibial tubercle tenderness compression, and elevation (RICE) is a ACL = anterior cruciate ligament; MCL = medial collateral ligament. good rule of thumb. Acetaminophen or nonsteroidal anti-inflammatory medica- tions may help with pain relief. The pa- tient can then be re-examined in about a flexion will help determine any anterior palpably greater than the uninjured side week’s time. instability. If present, this suggests a tear with a soft end-point would suggest a of the ACL. tear of the PCL. An anterior drawer test COMPLETE EXAM OF THE KNEE An effective Lachman’s exam re- at 90 degrees of knee flexion may test Again, an approach that works well quires a relaxed patient, so performing the integrity of the ACL, although the for the order of the complete knee exam this, with a gentle touch, prior to any ACL is under greatest tension at only 20 includes observing gait, examining other manipulation or palpation increas- degrees of knee flexion. Therefore, there hips, followed by the knee examination, es the chances the patient will be relaxed is a greater sensitivity for ACL deficien- focusing on the uninjured side before during the maneuver.
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