Ortho on the go
Ortho on the go
Anterior knee pain in adolescent male
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Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves. Thank you for joining me and welcome uh back to the podcast. So, another interesting case today. I think this is um something that we see quite often in all of our clinics uh throughout all of um the healthcare uh in our adolescent population, which is anterior knee pain. Now, there is a lot of varieties of anterior knee pain, and there could be a lot of different um diagnoses depending on the specific complaints of symptoms, the age of the patient, and if it's a male or female complaining about the symptoms. This happened to be a 12-year-old male who came in complaining about anterior knee pain. Uh, he'd had the symptoms for approximately two months. Um, he was currently participating in both basketball and cross-country activities. Unfortunately, these did overlap, and when they started to overlap, he noticed increased pain within the front of his knee. Initially, the pain was after he played basketball or running activities or just sports in general. Uh, but the pain progressively got worse to the point where it started to affect him and or um be present during everyday life activities and occasionally wake him up from sleep. The pain got severe enough where actually the day before he saw me, he was playing in a basketball game and asked to be taken out of the game during the third quarter because of the severity of the symptoms and pain. According to the patient, his mom, he tried to treat this conservatively with ICE, um topical anti-inflammatories, and some modified activities. He was a tall, a 12-year-old boy, had been growing recently. Um I think when you're discussing andor interviewing or kind of getting your history from adolescent patients, some of the things mentioned in this are definitely important to cover. I think one of the important things to cover is the severity of symptoms, and sometimes it's hard for them to discuss this with you, so I like to ask questions like, um, does it prevent you from playing sports? Because most kids want to play sports. And if the symptoms are severe enough where they can't play sports, I I think that registers in your mind that this is a pretty severe and or uh major complaint. Does it wake them up from sleep at night? Does it bother them during everyday life activities such as walking around school? Um, do they find themselves limping uh because of it? I think these are all important symptoms. And then oftentimes if it's an acute injury, like they got injured on the field, I always ask them if they were able to come off the field or walk off the field under their own power, um, secondary and or after the injury, which again I think helps to define the severity. Or did they finish the game and then the pain came on that night, which is you know, more inflammatory symptoms and acute symptoms. If they were able to finish the game and the pain came on that night, I think this is probably more inflammatory symptoms. I think structural symptoms such as meniscus tears and lingamitus tears, they wouldn't be able to play through. So again, this is kind of some of my questioning when I'm talking to these patients. So for this gentleman on his exam, he had diffuse tendinus throughout his anterior tibial tubercle area. He had diffuse edema noted throughout the area as well, uh, noticeable increased pain with active knee extension activities. He did, interestingly enough, have some atrophy seen on the left side versus the right side within his quadriceps. Definitely had some tightness bilaterally within the lumbar spine, posterior glutal, hip area with hip flexion, internal external rotation, as well as the hamstring and quadriceps area. I think, and we'll get into this later, some of this tightness definitely leads to a propensity to have these patients get this type of anterior knee pain. Again, I think when I'm examining any patient that comes in with knee problems, especially in the adolescent patients, I always like to check hip range of motion because I think oftentimes they'll have limitations with hip range of motion that can cause transfer of load andor compensation within the knee that can often cause anterior knee pain. And then for this gentleman, I like to check uh functional evaluations, which I think with my adolescent patients are very important because a lot of the time their soft tissue complaints are coming from functional deficits. And so for him, I had him do a bilateral and/or just normal squat. And you could see when he did this, he significantly transferred his load to his right side, where again, away from the affected side. Hard to tell whether this is secondary to the knee pain, which most likely it is, or some functional deficits, because again, some atrophy was seen within his left quadriceps and hamstring area. And then he was unable to form single leg stance and central leg squat activities without significant pain within the anterior knee area. And he did have some valgus caving with these single leg squat activities, which kind of then again leads to possible poor firing of his glutes on this side. So I think the diagnosis for this patient was kind of apophysitis of his tibial tubercle, or, you know, as we would call it, uh Oshgood Slaughter's disease. And as a reminder, the apophysis is an important functional structure, or it's an outgrowth of bone that typically serves as an attachment site for muscle, ligaments, and tendons. Um, oftentimes the apophysitis or inflammation of this apophysis is secondary to a traction injury to the cartilage and/or the bony attachment within this area. Most often it's an overuse injury. Uh children who are growing tend to have tight and inflexible muscles and tendons. Oftentimes the bony structures will grow faster than these tendons and muscles can stretch to keep up, and this will cause increased traction to the area of these uh attachments and oftentimes cause these injuries to happen. There's multiple different apophysis noted, and apophysitis is often seen in quite a bit of these, most of the time within the lower extremity. Some of the common ones in the lower extremity are the attachment of the patella tendon onto the tibial tubercle, as we discussed, which would be Osgood Slaughter's disease, the attachment of the patella tendon onto the patella, or the inferior aspect of the patella, which would be sending Larson Johansson disease, the calcaneus, which would be Seaver's disease, and then multiple locations around the hip, including the anterior-inferior iliac spine, which would be the rectus femoris attachment. And then the upper extremity can sometimes happen in kids. You can see this in the shoulder as well as the medial epicondylar area. As I discussed, this is a common injury that we often see. One of the interesting kind of statistics about this is that one-third of our school age kids will visit a health professional each year, typically for a sports injury. And a large percentage of these visits are secondary to apophysitis. Again, during the episodes, the growth of the bone length outpaces the lengthening of the associated muscles and tendons and typically causes this. One of the important things to know is that the apophysis is two to five times weaker than the surrounding structures, including the muscle tendon complex, the ligaments, and the bones. So this does tend to be a weak area within the skeletally growing school-aged kids, and these weak areas tend to be the areas that they most often get injured. And it typically comes with a gradual onset. So if an athlete comes in with kind of this gradual onset of increasing pain at this muscular tendinous uh ligamentous attachment site, um likely this is secondary to apophysitis within the area because again, this tends to be the weak area. During the examination, again, just like this patient, you'll often see localized swelling, uh, pain, uh, increased pain, and noted with active resistive activities. X-rays are always performed. Um, I think the x-rays often will show some form of abnormality. You have to be careful when reading these x-rays. So, initial in the presentation, the margins of the patellatendon will become blurred on these radiographs due to the soft tissue swelling. It's after about three to four months, well, you'll start to see some bony fragmentation at that tibial tuberosity. In the subacute stage, past this four-month period, often the soft tissue swelling will resolve and the bony ossicle will remain. And in the chronic stage, that bony fragments may fuse to the tibial tuberosity, which can then cause a normal appearance. But like myself and a lot of other adolescents, you'll have kind of a prominent uh tibial tubercle area secondary to kind of the old um apophysitis. Now, when I was playing basketball and had this when I was young, they often call this growing pains. Um, I really don't like that diagnosis, and I think that's a difficult diagnosis to give to families and patients, but that really is what it is. It's growing pains, and we know that as the growth plates closes, oftentimes the symptoms will completely go away. What would be a differential diagnosis? Well, for this particular problem, it'd be sending Larson Johansson syndrome, which is again apophysitis at that inferior patella tendon attachment uh off the inferior portion of the patella, Hoffus syndrome or Hoffus fat pad syndrome, which can often cause anterior knee pain, soft tissue or bony tumors, patella tendon avulsion or rupture, chondromalacea of the patella, patella tendonitis, possible infectious uh apophysitis, uh accessory ossification centers, um, and then possibly a proximal uh tibial or tibial tubercle fracture could all be differential diagnoses within this patient. But again, this patient had more of this progressive onset, not necessarily an acute onset. You can get apophysitis secondary to acute onset, so in some patients they will have an acute trauma and subsequently have uh pain after this, secondary to the inflammatory changes due to the trauma. So it is possible to get apophysitis after an acute injury and then with prolonged symptoms. Again, the primary goal of therapy is to reduce the patient's pain and swelling over the tibial tubercle area. For this reason, we do recommend to avoid these um sporting activities, jumping, repetitive loading activities that can cause increased traction to that area. Oftentimes, ice can be helpful. Um, those, you know, chopad or patella straps can redirect the forces of pull and sometimes cause symptomatic relief. Ibuprofen, neproxin, topical anti-inflammatories can be helpful, but physical therapy is really the mainstay of treatment, these exercises to improve the stretching uh andor um length of the muscles, especially the quadriceps, and then going into the hamstring and gastroacnemius muscle. I think also important is um teaching the patient how to land appropriately and activation of the uh gluteous muscles to kind of stabilize the um the patient during landing with a lot of these activities. This could be one of those injuries that we see secondary to sports specialization. Oftentimes, um, we do recommend reducing sports specialization. So having your son or family member um doing a andor being a unisport athlete all throughout their adolescent career before high school, oftentimes this allows them to excel at that particular sport, but only trains the body and the muscles and the joints in one specific movement, which then can lead to these overuse type injuries. So I think it's important to have these athletes specialize in multiple sports. Overtraining is um you know frequent as well. So for my patient, he was doing both cross-country and basketball at the same time, which oftentimes will lead to this lower extremity apophysitis uh to form. These are always difficult conversations to have with families as well as athletes in general, because really the answer to this is rest, discontinuation of activities, um, and kind of delaying symptoms as much as possible until you get closure of those physis andor apophysis. I think they can often do modified activities, the physical therapies, I said, is the mainstay of treatment to try to stretch these musculatures and tendons out. Oftentimes it's important to know where they're at in the season, specifically what sport they're playing, if this sport predisposes them to increase risk or injury to this area. So I think all these things need to be taken into consideration when talking about this with the family members and the patients. For this patient, we discussed possibly taking two weeks off of basketball activities, and he was okay with this because again, he asked to come out of the game, so he was in severe enough pain where he knew this was important. We start him in physical therapy activities. At two weeks, we'll reassess where he's at. If he's doing well, we can gradually progress him back into basketball activities over a one to two week period and see how things progress, and then again, modify his symptoms with these symptomatic treaters such as topical anti-inflammatories and these patella tendons traps. I think this is a common diagnosis we see. Again, a third of all adolescents uh andor school age kids will have soft tissue muscular stintenness problems, they'll present to clinics, physical therapy clinics, athletic trainers with. So this is something definitely to keep an eye out for. Know the anatomy, know the insertional points for these ligaments, and if there are apophysis within this area, and if there's a gradual onset of symptoms, think about this apophysitis as being the possible diagnosis with this. Thank you for listening to the episode. I hope you enjoyed the episode. Again, please reach out, uh, follow us on social media, both Instagram and Facebook. Uh, let us know if there's anything particular you'd like to see covered or any interesting cases that you had that we can maybe talk about.