1. Pediatric Painful Knee Emily C Dawson MD PL2 December 19, 2005

2.  Estimated 30 million children participate in organized sports each year  Pediatricians now primary medical resource for these active children  Sports are responsible for  > 10 million PCP visits each year – sports and overexertion leading cause  > 35% all medically attended injuries 5-17y  > 20% ED visits 5-24y  Musculoskeletal injuries are 2 nd most common reason for visits to ED/PCP

3.  Pediatric Residency Education: Is Sports Medicine Getting Its Fair Share? Pediatrics Jan 2005  US pediatric residency SM curricula, teaching methods and resident evaluation of SM education  Chief residents and PL3 randomly selected from 100 US ACGME accredited residency programs  Almost 1/3 program did not include musculoskeletal exam teaching in their curriculums  PL3 rated teaching of the joint exam and the preparticipation physical as most poorly taught components of physical exam

4.  Pediatric Residents’ Knowledge and Skill in Performing Physical Examinations of the Ankle and Knee. Pediatrics April 2001  Objective Structures Clinical Examination (OSCE) used to evaluate competency in assessing clinical problems – however OSCE involving musculoskeletal exam not published  Developed method for evaluating skill and knowledge of PE knee/ankle and reliability  Watched video, observed an attending and demonstrated correct technique by resident  Written and clinical evaluation at begin rotation, end of rotation and 9 months later – suboptimal at baseline and improved significantly after teaching intervention

5. Case #1 13 y/o junior high track star complains of intermittent left anterior knee pain. He denies any trauma to the knee. He tried to ease off training between track events, but the discomfort returned quickly. He has grown 4 inches in the past year.

6. Case #2 18 y/o female runner presents recurrent bilateral knee pain. She says over the last year her knees have been an intermittent source of discomfort. After running her knees ache for 1 hour then gradually improve. She also noticed that she has pain when walking down the stairs and rising from a seated position.

7. Case #3 17 y/o female soccer player presents to ED with a right knee that gave way and was unsteady. She was reaching up in hyperextension to play a ball and she felt a pop in her right knee. There was immediate swelling and she was carried off the field.

8. Case #4 16 y/o AAM was evaluated at clinic 6 days after sustaining an acute injury to his right knee while playing baseball. He had acute onset of R knee pain after striking out at bat. He heard a single clunk in his knee and noticed immediate pain and swelling. He was seen at a local ED and placed in a knee immobilizer and told to follow up with sports medicine. He noticed that the knee "gave out" on him several times since the accident.

9. Anatomy of Knee Joint

12. Evaluation of the Knee  Mechanism of Injury  Observation and Comparison  Standing/Walking  Genu varum/valgum/recurvatum  Palpation  Bones  Soft Tissue  Active and Passive ROM  Flexion 135 -140°  Extension 0°  Internal Rotation 10°  External Rotation 10°

13. Evaluation of the Knee  Stress Tests  Valgus/Varus  Anterior Drawer  Posterior Drawer  Lachmans  McMurray  Apprehension  Manual Muscle Testing  Hamstrings  Quadriceps  Internal Rotator  External Rotators

14. Evaluation of the Knee  Neurological Testing  Sensory  Motor  Deep Tendon Reflexes  Circulatory  Functional Tests  Straighten and bend knee  Stand  Deep knee bend  Pivot on planted leg  Jog  Zigzag  Cutting  Running  Single leg Hop

15. Observation

17. Palpation

18. Valgus/Varus Stress Test www.aafp.org

19. Valgus Stress Test

20. Varus Stress Test

21. Anterior Drawer Test www.uptodateonline.com

22. Anterior Drawer Test

23. Posterior Drawer Test www.uptodateonline.com

24. Posterior Drawer Test

25. Lachman Test www.uptodateonline.com

26. Lachman Test

27. McMurray Test www.uptodateonline.com

28. McMurray Test

29. Patellar Compression

30. Patellar Grind Test

31. Patellar Apprehension

32. Alignment

33. Case #1 13 y/o junior high track star complains of intermittent left anterior knee pain. He denies any trauma to the knee. He tried to ease off training between track events, but the discomfort returned quickly. He has grown 4 inches in the past year.

34. Osgood Schlatter  Anterior knee pain, gradually increases over time – running, jumping, kneeling  Active adolescents (13-14y boy/11-12y girl), recent growth spurt  Apophysitis of proximal tibial tuberosity at insertion of patellar tendon – avulsion of developing ossification center  PE: localized tenderness, soft tissue swelling – tibial tuberosity, reproducible pain with extension of knee against resistance, squatting  Benign, self limited, resolves 6-18months  Imaging: not needed, clinical correlation  Tx: strengthen quads, stretching quads and hamstrings, protective pad, ice and NSAIDS

35. Osgood Schlatter www.uptodateonline.com

36. Case #2 18 y/o female runner presents recurrent bilateral knee pain. She says over the last year her knees have been an intermittent source of discomfort. After running her knees ache for 1 hour then gradually improve. She also noticed that she has pain when walking down the stairs and rising from a seated position.

37. Patellar Grind Test

38. Patellar Compression

39. Alignment

40. Patellofemoral Syndrome  Overuse and overload  Retropatellar or peripatellar pain – physical and biomechanical changes in PF joint  Chronic anterior knee pain – during activity, descending steps, rising from seated position  Patella articulates in femoral groove – moves up/down, tilts and rotates → various points of contact  Many factors that effect stabilization  Flat feet (pronation) or High arches  Increased Q angle  Muscular weakness  Decreased flexibility  PE: pronation, flattened arch, patellas facing inward, underdevelopment VMO, +patellar grind, + compression  Imaging: AP. Lat and sunrise (axial) xrays  Tx: Rest, quad strengthening, stretching,evaluation of footwear, ice and NSAIDS

41. Case #3 17 y/o female soccer player presents to ED with a right knee that gave way and was unsteady. She was reaching up in hyperextension to play a ball and she felt a pop in her right knee. There was immediate swelling and she was carried off the field.

42. Anterior Drawer Test

43. Lachman Test

44. ACL Injury  Direct trauma, landing off-balance or cutting  Twisting or hyperextension when foot is planted and the knee extended  Often accompanied by other injuries - MCL and menisci  PE: acute hemarthrosis, + anterior drawer, + Lachmans  Imaging: MRI  Tx: nonsurgical vs surgical  Physical therapy and bracing – 6 months  ACL reconstruction

45. ACL Tear

46. Patellar Apprehension

47. Case #4 16 y/o AAM was evaluated at clinic 6 days after sustaining an acute injury to his right knee while playing baseball. He had acute onset of R knee pain after striking out at bat. He heard a single clunk in his knee and noticed immediate pain and swelling. He was seen at a local ED and placed in a knee immobilizer and told to follow up with sports medicine. He noticed that the knee "gave out" on him several times since the accident.

48. Patellar Dislocation/Subluxation  Twisting movement about the knee or trauma  Almost always dislocates laterally  Teens, girls> boys  Predisposition – weak VMO, patella alta, knock kneed, joint laxity or hypermobility  PE: lateral patella, 20-30° flexion, swelling, + apprehension test, medial joint line tenderness, pain with valgus stress  Imaging: pre/post reduction films (AP, lat & axial), MRI  Tx: Reduction – supine, hips flexed, extend knee while apply medial pressure to lateral side of patella. Immobilize, compression, elevation, ice and NSAIDS. PT – ROM, decrease swelling, strengthen quads.

49. Patellar Dislocation

50. References: Beasley L, Vidal AF. Traumatic patellar dislocation in children and adolescents: treatment update and literature review. Current Opinion in Pediatrics. 2004; 16: p29-36 Demorest R et al. Pediatric Residency Education: Is Sports Medicine Getting Its Fair Share. Pediatrics. January 2005: p28-33 Hergenroeder A. Causes of Knee Pain and Injury in the Young Athlete. www.uptodate.com www.uptodate.com Hergenroeder et al. Pediatric Residents’ Performance of Ankle and Knee Examination after Educational Intervention. Pediatrics. April 2001 Hergenroeder et al. Development and Evaluation of a Method for Evaluating Pediatric Residents’ Knowledge and Skill in Performing Physical Examinations of the Ankle and Knee. Pediatrics. April 2001 Juhn M. Patellofemoral Pain Syndrome: A Review and Guidelines for Treatment. American Family Physician. November 1999: p2012-2018 Kienstra A, Macias C. Osgood-Schlatter Disease. www.uptodate.com.www.uptodate.com