Morning Report
September 9th, 2011
Causes of knee pain in young athletes
Acute
Chronic
Ligament injuries (ACL, PCL, LCL, MCL)
Patellofemoral syndrome
Meniscal injuries
Ligament injuries
Patellar dislocation
Meniscal injuries
Popliteal tendinitis
Osteochondritis dessicans
Muscle injuries
Osgood-Schlatter
Referred hip pain
Iiliotibial band syndrome
Tendonitis
Prepatellar bursitis
Baker’s cyst
Discoid meniscus
Referred hip pain
Case #1
 A 12 yo boy has had left anterior knee pain for the past 2
months that is getting worse. He has had no known
injury and plays team basketball. He says that the pain is
worse after his basketball games. He has not tried any
meds to relieve the pain.You elicit tenderness over the
tibial tubercle, but he has no limitation of motion and the
knee is stable.
Case #2
 A 14 yo boy experiences acute left anterior knee pain
after sudden deceleration with the left foot planted
during a basketball game yesterday. He had immediate
pain and was unable to ambulate. On physical exam, he
holds the knee in flexion and has moderate joint effusion
with tenderness over the tibial tubercle.
Case #3
 A 15 yo girl who is a marathon runner presents with
bilateral anterior knee pain for the past 3 months that is
worsening. The pain is made worse by sitting for long
periods or climbing stairs at school. She denies any
recent trauma or illness. On physical exam, prolonged
hyperflexion of her knees reproduces her pain and is
relieve with extension. A Q-angle is 22 degrees, she has
full range of motion, and the knees are stable.
Case #4
 A 15 yo female soccer player has had pain in her left
knee since she twisted the knee while running 3 weeks
ago. Her left leg was planted on the ground and her knee
made a twisting motion. She had immediate pain and
swelling, which has now subsided. She reports that the
knee gives out when she tries to play soccer. On physical
exam, she has full range of motion of the knee without
effusion. The Q-angle is 15 degrees, and results of the
Lachman maneuver are positive.
Lachman maneuver
Case #5
 An 8 yo boy presents to clinic complaining of snapping in
his left knee that has been getting worse over the past 3
months. It is mildly painful and elicited by flexion and
extension. The pain localizes to the lateral side of his
knee. He denies trauma. There is no history of locking,
swelling, or instability. On physical exam, he has full
range of motion and a positive McMurray test.
McMurray Test
Affected knee is
maximally flexed
to start, then
gradually extended
applying a valgus
force and external
rotation of the
tibia
Case #1
 Dx:
 Osgood-Schlatter
 Imaging:
 Plain radiographs alone
 Management:
 PCP alone
 Treatment:
 Nonoperative
 Rest, ice, and anti-inflammatory meds
Osgood-Schlatter
 Exact cause unknown
 Major factor is excessive
force on the tibial tubercle
by the patellar tendon
 Rapidly growing
adolescents involved in
jumping and squatting
sports are most
susceptible
 Self-limited and resolves
once the growth plates
have closed
Case #2
 Dx:
 Tibial tubercle avulsion fracture
 Imaging:
 Plain radiographs primarily;
 MRI occasionally useful
 Management:
 PCP for initial care with planned referral to
orthopedic surgeon
 Treatment:
 Nonweighbearing
 Straight-leg knee imobilizer
Tibial tubercle fracture
 Common in male athletes 14-16 years old
 Typically knee is held in flexion
 3 types
 Type I – minimal swelling, can extend the knee, long leg cast
 Type II or III – large effusion, knee extension not possible,
treated with open reduction
Case #3
 Dx:
 Patellofemoral syndrome
 Imaging:
 No study generally required
 Management:
 PCP + physical therapy
 Treatment:
 Knee bracing, patellar taping, and anti-inflammatories
 PT for iliotibial band stretching and medial quadriceps
strenghtening
Patellofemoral syndrome
 Typically affects adolescent




athletes who engage in
running, jumping, and
squatting sports
A Q-angle > 15 degrees
causes maltracking of the
patella during knee flexion
and increases pressure on
femoral condyles
Vague knee pain with
activities like stairs and
squatting
Crepitus may be present
Plain radiographs not helpful
Case #4
 Dx:
 Anterior cruciate ligament tear
 Imaging:
 Both plain radiographs and MRI
 Management:
 PCP for initial care with planned
referral to orthopedic surgeon
 Treatment:
 Place into knee brace or immobilizer and crutches for
protective weightbearing
 Referral to ortho in 7 to 14 days
ACL Tear
 Sudden deceleration and
twisting force
 Cutting and pivoting sports
such as soccer and basketball
 More common in females
 Acutely present with inability to
bear weight, effusion, and
decreased range of motion,
which resolve over weeks
 Radiographs may demonstrate
an avulsion fracture of the
lateral tibial plateau (Segond
fracture) which is highly
suggestive of an ACL injury
Maneuvers
 Anterior drawer test
 Grasping the proximal tibia
and pulling the leg forward
with the knee flexed to 90
degrees and foot stabilized
 Lachman test
 Flexing the knee 15 to 30
degrees followed by
attempting to pull the tibia
forward with one hand while
holding the femur stationary
 More sensitive
*Excessive anterior tibial translation (forward motion) with either test
signifies an ACL injury
Case #5
 Dx:
 Discoid meniscus
 Imaging:
 Both plain films
and MRI
 Management:
 PCP; orthopedic surgeon for unstable lesions (meniscal
tear)
 Treatment:
 Initially nonoperative supportive care
 Once pain prevents physical daily activites, surgery is
considered
Discoid Meniscus
 Common cause of snapping or
popping of immature knee
 Abnormally disc shapped,
thick and have abnormal attachements
 Highest rates in East Asian populations
 Symptoms appear at age 4 or 5
 Pain with snapping at age 8 or 9
 McMurray test positive in meniscal pathology
 Plain films usually normal, but should be ordered to rule out
bony pathology
Noon Conference
Dr. Brown, GI Bleeds