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Pediatric Knee Pain: Diagnosis and Management
Pediatric Knee Pain: Diagnosis and Management
Ramsey Shehab MDDivision of Sports Medicine
Department of Orthopaedic SurgeryHenry Ford Medical Group
Ramsey Shehab MDDivision of Sports Medicine
Department of Orthopaedic SurgeryHenry Ford Medical Group
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Knee Pain Apophyseal injuries Patellar tendonitis Anterior knee pain Meniscal injuries Ligament injuries Articular cartilage
injuries
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Knee Anatomy Bony Structure
– Femur– Patella– Tibia/Fibula
Ligaments– Anterior Cruciate– Posterior Cruciate– Lateral Collateral– Medial Collateral
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Knee Anatomy Soft Tissue Structures
– Pes Bursa (Hamstring Insertion)
– Quadriceps Tendon
– Patellar Tendon
– Iliotibial Band
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History Traumatic vs Atraumatic
evaluation
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History - Traumatic Mechanism of Injury
– Sport/Activity
– Position of Knee
– Contact or Non-contact
Timing Swelling Stiffness Numbness Inability to bear weight Location of Pain Catching, Locking, Giving way
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History - Atraumatic Timing of Symptoms Pain
– Location
– Activity
– Rest
Swelling Improvement
– NSAIDs/Ice
– Rest
Catching, Locking, Giving way
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History
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Physical Examination
Inspection Palpation ROM Strength testing Special tests
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Patella
Hollow
Indented
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Medial Collateral Ligament (MCL)*
Pes anserine bursa**
Medial joint line
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Lateral joint line
Lateral Collateral Ligament (LCL)**
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Physical Examination Inspection
– Alignment
– Swelling
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Physical Examination Palpation
– Evaluate for an Effusion
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Physical Examination Range of Motion
– Extension– Flexion
Strength Testing– Quadriceps Straight leg raise
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Physical Examination Ligamentous Evaluation
– Lachman
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Physical Examination Ligamentous Evaluation
– Anterior Drawer
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Physical Examination Ligamentous Evaluation
– Posterior Drawer
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Physical Examination
Ligamentous Evaluation-Valgus stress
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Physical Examination Ligamentous Examination
-Varus stress
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Physical Examination Meniscal assessment
– Joint line tenderness
– McMurray’s Test
– Apley’s Grind Test
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Radiographic Evaluation Always start with X-rays
WB views if possible
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Radiographic Evaluation MRI for acute knee
injury with effusion/lack of motion
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When is it a concern? Inability to straight leg raise Effusion or stiffness related
to an injury Ligamentous laxity Catching, Locking, Giving way Inability to fully straighten
the knee related to injury
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Knee Pain Apophyseal injuries Patellar tendonitis Anterior knee pain Meniscal injuries Ligament injuries Articular cartilage
injuries
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Apophyseal Injury 2ndary ossification
centers where tendons insert
Growth spurt: bones grow faster than muscle
Overuse, training changes
Symptoms– Pain
– Swelling
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Apophyseal Injury Treatment
– Rest
– Ice
– Anti-inflammatory
– Knee strap
– Rehab
– Correction of training errors
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Patellar Tendonitis Inflammatory process at
the lower pole of patella Typically caused by
overuse Symptoms
– Pain
– Swelling
– Difficulty with steps and walking on inclined surface
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Patellar Tendonitis Treatment
– Period of Rest
– Ice
– Anti-inflammatory
– Knee strap
– Injections????
– Rarely Surgery
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Anterior Knee Pain
Patellofemoral pain Runner’s knee Multi-factorial Females Symptoms
-running-theatre sign-stairs
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Anterior Knee Pain
Treatment
– Rest/activity modif
– Ice
– Anti-inflammatories
– Physical Therapy
– Knee sleeve
– Rarely Surgery
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Meniscal Injuries Extremely common Traumatic vs atraumatic Lateral vs medial Cartilage loss as we age
leads to degenerative meniscal tears
Symptoms– Pain with activity– Catching and Locking– Minor Swelling
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Meniscal Injuries History
– Traumatic
– Twisting activity
– Catching, Locking
Physical Exam– Minimal swelling
– Joint Line Tenderness
– McMurray’s/ Apley’s +
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Meniscal Injuries Treatment
– Physical Therapy Strengthening Compensates for tear Does not heal injury
– Surgery Meniscal repair Mechanical symptoms Recovery ranges from 4-
8 weeks
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Ligament Injuries
Anterior Cruciate Posterior Cruciate Lateral Collateral Medial Collateral
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ACL Injuries Anterior Cruciate
Ligament– Resists anterior translation
of tibia against femur
– Low capacity for healing
History– Injury – noncontact or
contact
– Swelling, Stiffness, Pain
– Chronic – giving way, buckling of knee
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ACL Injuries Exam
– Lachman/Ant Drawer positive
– Effusion
– Chronic Tear – Pivot Shift
Radiology– Xrays
– MRI
Treatment– Often times surgical for
return to sport
– 6-9 month recovery
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PCL Injuries Posterior Cruciate
Ligament– Prevents posterior
translation of the tibia against the femur
– Greater Capacity for healing
History– Injury more often contact
or with multi-ligament injuries
– Swelling, Pain, Giving Way
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PCL Injuries Exam
– Posterior Drawer Positive
– Positive Tibial Sag
Radiology– Xrays
– Mri
Treatment– Low grade injuries –
nonoperative
– Grade III/Multi-ligament injuries - Reconstructed
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Medial/Lateral Collateral Injuries Allow for medial and lateral stability
– Good Healing potential
History
– Contact or Non-contact
– Minimal Swelling
– Medial/Lateral Pain
Exam
– Pain over origin/insertion of ligaments
– Opening Varus/Valgus stressing (0/30 degrees)
Treatment
– Rest, Ice, Bracing, advancement of ROM
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Articular Cartilage Injuries
Can be Acute or Degenerative
Difficult to Diagnose Symptoms
– Pain, Catching
– Swelling
– Pain specific location/activity related
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Articular Cartilage Injuries Radiology
– Xrays/MRI (Cart Seq.)
Treatment– Nonoperative Rest, Ice Compression PT
– Operative Microfracture OATS Carticel Osteochondral Allograft