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Copyright © 2015 Wolters Kluwer Health, Inc. All Rights Reserved. 2.5 CONTACT HOURS a Review of Knee Pain in Adolescent Females 28 The Nurse Practitioner • Vol. 40, No. 17 www.tnpj.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. 2.5 CONTACT HOURS A review of knee pain in adolescent females Abstract: Primary care practitioners are in a position to educate patients and parents about the risk factors that may increase the incidence of knee pain in adolescent females. This article highlights patellofemoral pain syndrome, Sinding-Larsen- Johansson syndrome, Osgood-Schlatter disease, and meniscal tears. By Rachel Lipman, MSN, CPNP and Rita Marie John, EdD, DNP, CPNP, PMHS cute and chronic knee pain is a common complaint in the adolescent female population. Moderate-to-severe cases may even lead to disability. A Studies show that up to 31% of adolescents suffer from knee pain, and there are a number of risk factors that predispose adolescent females to higher rates of injury.1 Female athletes have a prevalence of injury one and a half to three times higher than their male counterparts.1 Athletics are a major cause of knee pain in females, but proper training programs may reduce the incidence of pain and knee damage.2 Although some injuries are inevitable, the most effective method of reducing knee pain in fe- males is to prevent injury altogether. This review will focus on the most common types of knee pain in the adolescent female as well as risk factors, prevention, and management. ■ Etiology Both acute and chronic knee pain are commonly seen in adolescent females. Acute pain is typically caused by trauma during athletic participation, and chronic pain is commonly a result of overuse.3 Cutting and twisting sports, such as soccer, Keywords: adolescent females, knee pain, meniscus, Osgood-Schlatter disease, LZF / iStock © patellofemoral pain syndrome, Sinding-Larsen-Johansson syndrome www.tnpj.com The TheNurse Nurse Practitioner Practitioner • January • July 2015 29 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. A review of knee pain in adolescent females basketball, volleyball, and football are often associated with adolescent female population. Sinding-Larsen-Johansson ligament and meniscal injuries. Runners are more often (SLJ) syndrome is similar to Osgood-Schlatter disease and diagnosed with overuse injuries, such as patellofemoral most commonly present in males ages 10 to 14; it often pain syndrome and Osgood-Schlatter disease (see Sports presents in adolescent female athletes.10 SLJ syndrome is and associated knee injuries). also described as an overuse injury and is due to repeti- Patellofemoral pain syndrome. Patellofemoral pain tive pressure, tension, and traction by the patellar tendon syndrome (PFPS) is a frequent injury in adolescent females, on the still cartilaginous lower pole of the patella during and although its etiology is not completely clear, it is likely quadriceps contraction.10 due to overload on the knee joint.4,5 PFPS most commonly Meniscal lesions. Meniscal tears are a common injury in presents as anterior knee pain or nonspecifi c knee pain.6 adolescent females.11 Both the medial meniscus (MM) and PFPS may be diffi cult to diagnose because it is a multidi- lateral meniscus (LM) lie within the patellar joint and act mensional injury that mainly stems from the interaction primarily as shock absorbers for any outside force as well as between a person’s intrinsic anatomy and their training and a lubricant for the articular cartilage.12 Twisting and cutting exercise.7 Adolescents experience PFPS at higher rates than sports place adolescents at higher risk for a meniscal tear. the rest of the population.1 Additionally, meniscal lesions may accompany more severe Osgood-Schlatter disease and Sinding-Larsen- ligament injury and occur in greater than 80% of all anterior Johansson syndrome. Osgood-Schlatter disease is a com- cruciate ligament (ACL) tears.12 mon overuse injury that leads to chronic pain in early adolescence prior to growth plate closure. It presents with ■ Pathophysiology pain and swelling over the tibial tuberosity where the pa- Anterior knee pain is a common chronic complaint for tellar tendon attaches the quadriceps muscle to the tibia. adolescent females. Chronic pain is multifactorial and can Repetitive movement leads to infl ammation of the inser- occur as a result of overtraining. Acute pain is more likely tion site.8 Osgood-Schlatter disease coincides with periods due to a traumatic injury. Knee injury and pain can have of rapid growth; therefore, females between ages of 8 and lifelong complications if not managed properly. (See Knee 12 and males 12 and 15 years are most likely to develop joint anatomy.) symptoms. Furthermore, participating in running, vol- Patellofemoral pain syndrome. Patellofemoral pain is leyball, basketball, and soccer place teens at highest risk.9 thought to be due to anatomical and biomechanical fac- Although it is more often seen in males, Osgood- tors.13 This syndrome is characterized by infl ammation of Schlatter disease should also be considered in the early the synovial lining (soft tissue that lines the joint), infl am- mation of the fat pad, elevation of the intraosseous pressure, and an increase in the metabolic activity in the patellar Sports and associated knee injuries25,36 joint.4 The combination of infl ammatory processes is best described as a loss of homeostasis of the knee joint.4 PFPS Basketball/volleyball is an exceedingly prevalent overuse injury in adolescent fe- • Ligament injury males. The best method of prevention is to highlight the im- • Meniscal tear 14 • Osgood Schlatter disease portance of rest periods throughout the training process. • SLJ syndrome Osgood-Schlatter disease and Sinding-Larsen- Johansson syndrome. Osgood-Schlatter disease is generally Running • PFPS recognized as an overuse injury and is described as a traction • Osgood Schlatter disease apophysitis of the tibial tuberosity.9 Apophysitis is defi ned as • SLJ syndrome infl ammation and microtrauma to the apophysis of a bone.15 Skiing During periods of rapid growth, the apophysis is weakened • Contusion and is therefore more susceptible to damage. Repetitive move- • Ligament injury ments place stress on the tibial tuberosity and cause multiple • Meniscal tear 8 • Patellar dislocation micro avulsion fractures in the apophysis. Fortunately, most patients will heal after a period of rest from athletic participa- Soccer • Ligament injury tion and physical therapy, and symptoms are not likely to be • Meniscal tear present following the fusion of the growth plates.8 • PFPS SLJ syndrome occurs following periods of repetitive • Osgood Schlatter disease strain in adolescent athletes. Repetitive traction of the • SLJ syndrome patellar tendon during quadriceps contraction causes 30 The Nurse Practitioner • Vol. 40, No. 7 www.tnpj.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. A review of knee pain in adolescent females Knee joint anatomy Patellar ligament Patella Patellar surface of femur Medial Anterior cruciate Lateral condyle condyle Medial ligament of femur of femur condyle of femur Lateral condyle Lateral Posterior of femur epicondyle cruciate ligament Medial meniscus Fibular collateral Fibular collateral Anterior ligament ligament Posterior cruciate Lateral ligament cruciate Lateral ligament meniscus meniscus Medial Posterior Transverse meniscus Tibial meniscofemoral ligament collateral Tibial collateral ligament of knee ligament ligament Posterior Head of fibula Popliteus ligament of Patellar ligament fibular head Fibula Tibia Tibial tuberosity Fibula A Anterior view B Posterior view Source: Moore KL, Agur AM, Dalley AF. Essential Clinical Anatomy. 4th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2011:387. an increase in pressure and tension on the lower pole of playing sports on a hard surface may contribute to lower the patella.10 The increased forces on the patella in turn leg injuries.17 causes effusion, pain, cartilage damage, tendon thicken- Intrinsic factors (those that are inherent to the individ- ing, fragmentation of the lower pole of the patella, and ual) include age, gender, anatomy, fl exibility, coordination, bursitis. Ultrasound is diagnostic and may reveal edema, and proprioceptive skills, fi tness level, nutrition status, and fragmentation of the lower pole of the patella, patellar prior injuries.16 tendon thickening, and bursitis.10 Although females have certain inherent risks, there are Meniscal lesions. The patellofemoral joint includes numerous modifi able factors that can be targeted by inter- both the MM and LM. Each meniscus is a vascularized ventions to reduce knee injuries. Neuromuscular training extracellular matrix and acts primarily as a shock absorber programs that aim to increase coordination and proprio- between the tibia and femur.11 LM tears are most likely to ceptive skill while addressing muscle-tendon imbalance occur when the foot is planted and a valgus force is put on a may reduce the incidence of ACL injuries in adolescent bent knee. This torque causes the femur to rotate externally female athletes.16,18 (See Modifi able and nonmodifi able risk and tear the meniscus. MM tears occur when the foot is factors for knee pain and injury.) planted, a varus force is put on a bent knee, and the femur Obesity and fitness. Obesity in children and adoles- rotates internally.11 When intact, the menisci have a smooth cents has increased dramatically over the past two decades. and shiny surface, but once a tear occurs, the once slippery Increased weight causes a mechanical overload on the lower surface
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