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Common Causes of Adolescent Knee Pain

Common Causes of Adolescent Knee Pain

by | Aug 12, 2021 | Research & Innovation

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon Philip L. Wilson, M.D.
 
You can watch the full lecture and download this summary.
 
Diagnosing common causes of adolescent knee pain can be confusing, but it can be simplified by looking at history and physical findings during the exam systematically. To narrow the list of common causes, symptoms are broken down in three ways:

  1. Acute vs. Chronic presentation
  2. Effusion vs. No Effusion
  3. Primarily a Pain Problem vs. Primarily a Motion Abnormality

Below is a list of common knee conditions:

  • Sprain
  • Contusion
  • Stress Fracture
  • Apophysitis
  • Patellofemoral Dislocation
  • ACL Tear
  • Tibial Spine Fracture
  • Meniscal Pathology
  • Osteochondritis Dissecans

Conditions with an Acute Presentation
If the presentation is acute instead of chronic, the number of potential diagnoses becomes much smaller:

  1. Acute vs. Chronic presentation: Acute
    • Sprain
    • Contusion
    • ACL Tear
    • Tibial Spine Fracture
    • Meniscal Pathology

By determining if there is an effusion, or a collection of fluid within the joint, the list of common diagnoses narrows even further:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: No Effusion
    • Sprain
    • Contusion

Then, the likely diagnosis can be determined by looking at where the patient’s pain is located:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: No Effusion
  3. Primarily a Pain Problem vs. Primarily a Motion Abnormality: Primarily a Pain Problem

If the patient has soft tissue swelling and pain around the joint with nothing focal, no bony tenderness and no effusion, it is most likely a sprain.

  • Treatment
    • Protect, Rest, Ice, Compression, Elevation (PRICE)
      • Sometimes an Ace wrap, a splint or a brace is used to immobilize and protect the joint
    • Early protected range of motion
      • Get the patients up and moving early
    • Restore strength

Patients do not need to be referred to Scottish Rite unless their pain lasts for more than three or four weeks.
 
If the patient has an acute problem with an effusion, different common causes of adolescent knee pain from the list are likely:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: Effusion
    • Patellofemoral Dislocation
    • ACL Tear
    • Tibial Spine Fracture
    • Meniscal Pathology

To determine the cause, consider the motion associated with the injury to further narrow down the list of diagnoses:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: Effusion
  3. Pain vs. Motion Abnormality: Motion Abnormality
  • Patellofemoral Dislocation
    • Twist and valgus
    • “Knee dislocated”
  • ACL Tear
    • Twist and valgus
    • “Gave out” / “shifted”
  • Tibial Spine Fracture
    • Hyperflexion
  • Meniscal Pathology
    • Twisting event

Knee Injury and Effusion
How to tell if the patient has an effusion, not soft tissue swelling:

  • X-ray – side view image of the knee
    • Look at the kneecap as it is related to the thigh bone.
    • Look at the muscle coming off the kneecap
    • Look at the space between the kneecap and the femur
      • If there is a curvilinear density that is not the linear muscle, not the deep muscle or the fat pad, it is most likely an effusion.
  • Physical examination
    • Compare the patient’s knees
      • A knee with an effusion will look bulbous and will not have all the concavities around the patella of a normal knee
    • Push on the tissues around the knee
      • If the fluid can be moved from lateral to medial or if you can see a fluid wave, it is most likely an effusion
        • Soft tissue swelling cannot be moved around
X-ray of a knee

Knee Effusion – Patellar Dislocation
When a patient has a patellar dislocation, they relate an instability event where they knee “popped out of place.” There is also an effusion.

  • Diagnosis
    • Apprehension sign
      • While pushing down on the medial kneecap, the patient becomes apprehensive and will sometimes try to stop the exam because they think that their kneecap will become dislocated.
    • “J” sign
      • As the knee is flexed, the kneecap visibly jumps from out of the groove to back into place.
  • Treatment
    • PRICE
    • Physical therapy (PT)
    • Surgery

Refer patients to Scottish Rite for continued effusion or recurrent instability.

Knee Effusion – ACL Tear
When a patient describes twisting their knee and it giving out on them or shifting and they have an effusion, they most likely have an ACL tear. Their knee is unstable. There are four ligaments in the knee: the medial knee ligament and the lateral collateral ligament on each side, with the anterior cruciate ligament (ACL) on the front and the posterior cruciate ligament on the back. When the ACL is torn, the knee has more motion, so patients say that their knee slipped or gave out. The best way to check for a torn ACL is the Lachman test.

  1. The patient lies on their back with their legs out straight and their muscles relaxed, especially their hips and hamstring muscles.
  2. Bend the patient’s knee slowly and gently to about a 20-degree angle. Physicians may also rotate the patient’s leg so their knee points outward.
  3. Stabilize the patient’s thigh with one hand and gently move the tibia forward with the other hand.
    • If there is a great deal of of motion and instability, it is likely because the ACL is torn

Treatment

  • Surgery may be necessary to repair instability or an associated meniscal injury.

Refer any patients with a suspected ACL tear to Scottish Rite.

Knee Effusion – Tibial Spine Fracture
With a tibial spine fracture, the patent usually has a large effusion called a hemarthrosis, or blood in the joint, because of the fracture. These are usually caused by a flexion event like a fall from a bike or skiing or a twist in sport. This fracture will leave a fragment within the “notch” between the thigh bone and the shin bone. This is because instead of the ACL tearing in the middle of the rope, it pulls that piece of bone.
Treatment

  • Surgery
    • Put the piece of bone back in place
  • Casting
    • Moving the leg and putting it in a cast may work if it can be placed in a good position

Refer patients to Scottish Rite for immobilization or surgery.
Knee Effusion – Meniscal Tear

It the patient’s reports a twist or pop event and their effusion appears small while experiencing pain on the side of their joint, it is most likely a meniscal tear. Other things to look for to make the diagnosis are focal joint line pain, a loss of extension, a negative Lachman exam, no patellar apprehension, and nothing positive on their X-rays. An MRI may be needed to confirm the diagnosis. The effusion usually means that there is an internal derangement that needs to be treated with surgery.

Conditions with a Chronic Presentation
If the athlete’s injury is a chronic injury, a different set of diagnoses becomes likely:

  1. Acute vs. Chronic presentation: Chronic
  • Stress Fracture
    • Has been sore for a while
  • Apophysitis
    • Pain at the growth plate
  • Patellofemoral Dislocation
    • Pain around the kneecap
    • Not a specific injury
  • Osteochondritis Dissecans
    • An idiopathic osteonecrosis below the cartilage surface during development

These conditions generally do not have an effusion, and are all activity-related knee diagnoses.

  1. Acute vs. Chronic presentation: Chronic
  2. Effusion vs. No Effusion: No Effusion
  3. Pain vs. Motion Abnormality: Pain

To determine which condition it is, find out where the pain is located.

  • Stress Fracture
    • Focal distal femur or proximal tibia
    • Tender over a small area around a bone
  • Apophysitis
    • Focal distal patella or tibial tubercle
    • Focally tender
  • Patellofemoral Dislocation
    • Poorly localized / Not focally tender
    • “Horseshoe” sign
  • Osteochondritis Dissecans
    • Cannot localize
    • Deep within

Slipped Capital Femoral Epiphysis (SCFE)

ALWAYS CHECK THE HIP IN ADOLESCENTS WITH KNEE COMPLAINTS

When adolescents have activity related knee pain, often with no inciting event, and display symptoms including a limp, walking with their foot externally rotated and a limited range of motion (especially with internal rotation), it may be SCFE. SCFE is checked with a hip rotational exam. If the patient has equal symmetric range of motion, physicians can rule out SCFE and move on to other diagnoses.

Overuse Conditions – Stress Fracture
Stress fractures are an activity-related pain that often happens after periods of inactivity, like summer. They are associated with high activities like running. Patients are focally tender on their bone, but their knee joints are fine. An X-ray usually shows a stress fracture on their distal femur. The treatment for a stress fracture is forced rest until the patient is pain-free and a gradual return to sports.

Overuse Conditions – Apophysitis
Apophysitis is an activity-related condition with pain focal to only one place. The growth plate is going through a transition with a great deal of stress applied in that area with activities. The two main apophysitis to consider are Osgood-Schlatter Disease in which the patient’s pain is on the tibial tubercle, and Sinding-Larsen Johansson (SLJ) Syndrome in which the pain is on the inferior pole of the patella. The treatments for apophysitis are rest, anti-inflamitories, and quad stretching.

Patellofemoral Pain Syndrome
Unlike Osgood-Schlatter Disease and Sinding-Larsen Johansson (SLJ) Syndrome, the patient cannot pinpoint their pain with Patellofemoral pain syndrome. Patients motion all around the knee in what is called the “Horseshoe” sign. They do not have instability in their knee, but they do have pain around their kneecap. The cause of Patellofemoral pain syndrome is unknown, but it is believed to be related to an abnormal balance of the homeostasis of the muscle strength around the front of the knee. During the exam, physicians determine the “Q” angle, or the quadriceps angle. This is the angle between the quadriceps tendon and the patellar tendon. This angle provides useful information regarding the alignment of the knee joint. “Q” angles greater than 14° are vulnerable to patellar conditions. Physicians also look for poorly developed vastus medialis oblique muscle (VMO), a “J” sign, and pain with patellofemoral compression.

Treatment

  • Physical therapy
    • Quadriceps strengthening
    • Knee balance
    • Knee proprioceptive strengthening
  • 70% improved with physical therapy, regardless of associated interventions.

Osteochondritis Dissecans (OCD)
OCD is an idiopathic osteonecrosis below the cartilage surface during development. This can lead to cartilage surface cracks, instability and lesion on the joint. OCD can happen with or without trauma. In an X-ray, a radiolucent lesion is visible.

  • 2:1 Male to female
  • 33% Bilateral

The younger the patient is and the smaller they are, the more likely they are to heal. The location of lesion and the status of articular surface also play a factor in the patient’s healing potential.

Treatment

  • Forced rest
  • Unloader brace
  • Surgery if the patient is older or if the MRI reveals instability.

Meniscal Pathology
A meniscal pathology has a chronic presentation with no effusion, but a motion abnormality instead of pain.

  1. Acute vs. Chronic presentation: Chronic
  2. Effusion vs. No Effusion: No Effusion
  3. Pain vs. Motion Abnormality: Motion Abnormality

The patient says that their knee pops or snaps. They may also have a loss of extension and a limp. These are signs of a discoid meniscus.

Discoid Meniscus

  • Discoid meniscus is a congenital malformation of the meniscus
    • Affects approximately 1:100 children
  • Mechanical symptoms in childhood with no trauma history
    • Snapping in the knee usually occurs between the ages of 2 to 6.
  • Palpable / audible “snap” at lateral joint line during exam
  • Visible bulge at lateral joint line

As children get older, the discoid meniscus presents like a regular meniscal tear. The treatment for this condition is arthroscopic surgery if the patient is symptomatic.

Refer patients to Scottish Rite for mechanical symptoms or loss of motion.

Therapeutic Camps Improve the Self-Esteem and Confidence of Kids with Hand Differences

Therapeutic Camps Improve the Self-Esteem and Confidence of Kids with Hand Differences

by | Jul 9, 2021 | Research & Innovation

Scottish Rite for Children is world-renowned for its patient-centered care for children with orthopedic conditions. Our Center for Excellence in Hand is committed to caring for children with hand and upper limb conditions. The center is focused on providing innovative treatment to help patients live active and independent lives. Occupational Therapist and Certified Hand Therapist Amy Lake, has recently published The impact of therapeutic camp on children with congenital hand differences in the Cogent Psychology.

The goal of this study was to evaluate the efficacy of hand camp by investigating camp participation and outcomes on self-esteem, physical function, activity participation, and peer relationships. Forty patients with a congenital hand difference seen in hand clinic between the ages of 10 and 13 were eligible to attend hand camp. Following hand camp, Peer relationships, upper extremity function, and self-esteem improved immediately. Upper extremity function and self-esteem scores continued to improve significantly throughout the 6-month follow-up period. The authors of the study believe that research related to therapeutic camping experiences is integral when identifying best-practice interventions to increase the quality-of-life outcomes for children with congenital hand differences.

To date, no research has been conducted on the effects of camp participation in the pediatric congenital hand difference (anomaly) population. Another goal of this study was to evaluate the efficacy of a therapeutic hand camp for children with a congenital hand difference. Attendees of the 2015 Tween Camp (ages 10–13 years) completed self-report assessments of self-esteem, function, participation in activities, and relationships with peers. Attendees also completed an assessment to determine if they believed camp objectives were met. This specific camp was chosen for the initial study due to the camp attendees’ ability to complete assessments independently.

Some of the key takeaways from this study are:

  • Participants reported that their upper extremity function had significantly improved from pre-camp to immediate follow-up
  • Participants expressed a significant improvement in their self-esteem from pre-camp to immediate follow-up
  • Following camp, participants indicated improved skills in peer interaction, daily physical activities, willingness to try new things and confidence in explaining their hand difference.

This suggests that following camp, a child is: more apt to participate in extracurricular activities; have higher self-esteem with regard to their hand difference; be more independent in activities of daily living; and manage negative reactions from others regarding the appearance of their hand. This supports the hypothesis of the study, that camp can indeed make a positive impact on children with congenital hand differences.

Because of the success of our hand camps, Scottish Rite for Children has helped start-up hand camps around the globe based on our Hand Camp Model including camps in Florida, Missouri, California, Italy, and England. Coming soon to Australia.

Learn more about hand research.

Sports Medicine and Psychology Experts Work Together – Caring for the Whole Child

Sports Medicine and Psychology Experts Work Together – Caring for the Whole Child

by | Oct 6, 2020 | Research & Innovation

Our Sports Medicine team noticed that a commonly used outpatient depression screening questionnaire was identifying more patients than were actually at risk for concerns for suicide. This created an excessive number of alerts to the clinical team to assess patients that were not at risk, which is called a high false positive rate. The team implemented changes to reduce that rate without missing those patients that were truly at risk and needed further evaluation.

Jane S. Chung, M.D., sports medicine physician, says, “Suicide is now the second leading cause of death among young people 10-24 years of age, and is a serious public health problem in our youth. Often, in the sports medicine setting, these kids who are hurting and struggling internally are the ones coming in to see you for sports-related injuries and other musculoskeletal ailments,” says Chung. “Our team felt it was important to look into this trend in our own outpatient clinics to come up with a strategy to best identify those patients at risk so we can provide early intervention, as early identification and intervention is key in helping these youth at risk.” Success with the effort would allow resources to be properly allocated to the right patients.

Partnering with the Psychology and Research teams, the group developed a new strategy to decrease the high false positive rate in screening questionnaires utilizing a staged process in the electronic medical record. Additionally, patients were given the opportunity to review their responses before submitting, as often young patients can misread or answer a question too quickly on the iPad questionnaires. The clinical staff was then notified of those patients who provided responses that were concerning for suicide risk.

Recently, in March 2020, the team implemented a more pointed suicide screening questionnaire with hopes that future analysis will show continued improvement in identifying those youth at risk. The staged approach effectively identified patients in need of intervention and the false positive rate drastically improved. Researcher, Connor Carpenter says, “Quality improvement projects like this one have a real impact on our patients and our system. When patients get treatment they need and not the treatment they do not, everyone wins.”

This study, “Effective Administration of Mental Health Screening Tools Affects Appropriate Allocation of Resources and Improves Clinician Ability to Identify Those at Risk for Suicide,” was shared as a medical poster at the 2020 virtual annual meeting of the American Academy of Pediatrics.

Learn more about mental health in young athletes in a previous article.

Limb Reconstruction Meeting Brings Experts from Around the World to Dallas

Limb Reconstruction Meeting Brings Experts from Around the World to Dallas

by | Feb 7, 2020 | Research & Innovation

Scottish Rite Hospital is honored to host the second annual Controversies in Pediatric Limb Reconstruction (CPLR). This two-day seminar brings together leaders in the field to collaborate and discuss the latest treatment techniques for pediatric patients with limb deformities, limb loss, musculoskeletal infection and severe length discrepancies. 

In conjunction with the Limb Lengthening and Reconstruction Society (LLRS) and the Pediatric Orthopaedic Society of North America (POSNA), the program includes lectures, panel discussions and case studies presented by hospital staff and international guests. Co-directed by pediatric orthopedic surgeon David A. Podeszwa, M.D., and researcher Mikhail Samchukov, M.D., CPLR serves as a unique opportunity to bring together experts from various backgrounds who provide care to this specific patient population.

As a leader in this specialty, the Center for Excellence in Limb Lengthening team travels the world to teach others about the devices used to treat conditions associated with limb deformities. CPLR cultivates local and international collaboration right here in Dallas, TX. 

“We are excited to host this prestigious event,” says Podeszwa. “We have the opportunity to collaborate with some of the best from around the world, right here in our hospital, to advance the care provided to these patients. CPLR gives attendees a focused and comprehensive program where they are able to learn, debate and discuss the latest treatment techniques – with the hopes that they take that knowledge and apply it at their respective institutions worldwide.”

Learn more about our Center for Excellence in Limb Lengthening.  

Scottish Rite Hospital Hosts Prestigious Hand Conference

Scottish Rite Hospital Hosts Prestigious Hand Conference

by | Oct 11, 2019 | Research & Innovation

Scottish Rite Hospital’s Charles E. Seay, Jr. Center for Excellence in Hand Disorders is committed to caring for children with hand and upper limb conditions. The center is focused on providing innovative treatment to help patients live active and independent lives. In addition, the hospital’s hand team has become the leader in training hand surgeons from across the globe.

This week, the hospital is hosting the Marybeth Ezaki/Peter Carter Visiting Professorship. Established in 2017, this two-day conference brings together pediatric upper extremity surgeons, as well as other orthopedic surgeons, to discuss the latest treatment techniques in caring for children with complex hand conditions. The visiting professorship is in honor of Marybeth Ezaki and Peter Carter, both former staff hand surgeons who provided world-renowned care and innovation during their time at the hospital.

The hospital is welcoming Steve E.R. Hovius, M.D. – a certified plastic and hand surgeon from Radboud University Medical Centre Nijmegen and at the Xpert Clinic Hand and Wrist Centre Rotterdam. He brings decades of experience, serving as the head of the department of Plastic and Reconstructive Surgery and Hand Surgery at the Erasmus University Medical Centre Rotterdam. The meeting also includes presentations and discussions from hospital staff.

Director of the hand center and co-director for this program Scott Oishi, M.D., FACS, is proud to host such a prestigious group. “Treating pediatric hand conditions can be tricky,” says Oishi. “It requires a specialized team who is dedicated to learning and advancing their techniques. This program is unique in that it brings together hand specialists, both near and far, to discuss the care and treatment of a pediatric hand patient and collaborate on current research.”

Learn more about the hospital’s Center for Excellence in Hand Disorders.

Hospital Doctors Lead the Research and Education in Children with Clubfeet

Hospital Doctors Lead the Research and Education in Children with Clubfeet

by | May 31, 2019 | Research & Innovation

At Scottish Rite Hospital, we are dedicated to providing world-renowned patient care. Our team of experts are able to do so through their steadfast commitment to advancing treatment through research and education. The hospital’s physicians and clinical staff are known worldwide for the research conducted in our Center for Excellence in Foot.

Clubfoot is one of the most common pediatric foot conditions that our experts treat. Through research, our team can study this patient population to better understand the condition and develop innovative treatment plans. With voluntary participation from patients, the team is able to review outcomes after treatment and assess how a child with clubfeet is functioning.

Recently, the hospital published two articles on their latest clubfoot research. Below is what our team is learning:

Functional Outcomes of Patient with Clubfeet at 10-year Follow-up
This research was led by Assistant Chief of Staff Lori A. Karol, M.D., Movement Science Manager Kelly Jeans, M.S., and other staff from the Movement Science Lab.

Summary

Our team analyzed outcomes of patients’ feet who received either the Ponseti serial casting (a form of treatment that places a cast from the thigh to the toes after gentle stretching of the foot) or French physiotherapy (daily stretching, exercise and massage, and taping to slowing move the foot to the correct position), and those who later required subsequent surgery. The Movement Science Lab recorded gait analysis, ankle strength, daily step activity and parent-reported outcomes of patients 10 years after receiving treatment.

What We Learned

  1. Children with clubfeet have less range of motion, movement and power in their ankle in comparison to children with normal feet.
  2. There are minimal differences in gait, parent-reported outcomes and daily activity between feet treated with Ponseti casting or physical therapy.
  3. Feet that did not receive surgery had better ankle power and muscle strength than feet requiring invasive joint surgery.

Clinical Significance

This study supports our efforts to minimize invasive joint surgery when treating a patient with clubfoot. Functional studies such as this continue to help our doctors in developing treatment plans for patients diagnosed with clubfoot.

Read the full article

Non-operative Treatment Outcomes for Patient with Non-Idiopathic Clubfeet
This research was led by Chief Medical Officer B. Stephens “Steve” Richards, M.D., and nurse practitioner Shawne Faulks, M.S.N., R.N., C.N.S.

Summary

Our doctors regularly diagnose and begin treating clubfoot during infancy. Since much of the non-operative treatment takes place before developmental milestones, some patients who were initially thought to have “idiopathic” (no known cause) clubfoot may develop other conditions throughout development rendering a “non-idiopathic” diagnosis. Little is known about the treatment outcomes of this population. Therefore, the purpose of this research is to better understand the clinical outcomes of patients who were later found to have non-idiopathic clubfoot, and how their outcomes compare to patients who have idiopathic clubfoot.

What We Learned

  1. Nearly 1 in 10 infants with idiopathic clubfoot were found to later have non-idiopathic clubfoot due to other orthopedic, neurological or developmental disorders.
  2. Non-idiopathic patients can be expected to respond favorably to non-operative treatment.
  3. Patients later found to be non-idiopathic had a greater chance for clubfoot recurrence that required surgery.

Clinical Significance

This study demonstrates the importance of developmental assessments during a child’s clinical visit. Pediatric orthopedic specialists should be proactive in evaluating more than just clubfeet or other orthopedic disorders during follow-up exams.

Read the full article

Learn more about the research in our Center for Excellence in Foot.