Morning Report

1. Morning Report September 9th, 2011

2. Causes of knee pain in young athletes

3. 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.

4. 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.

5. 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.

7. 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.

8. Lachman maneuver

9. 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.

10. McMurray Test Affected knee is maximally flexed to start, then gradually extended applying a valgus force and external rotation of the tibia

11. Case #1 • Dx: • Osgood-Schlatter • Imaging: • Plain radiographs alone • Management: • PCP alone • Treatment: • Nonoperative • Rest, ice, and anti-inflammatory meds

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Noon Conference Dr. Brown, GI Bleeds