Diagnosis and Treatment of Chronic Knee Pain Albert

Diagnosis and Treatment of Chronic Knee Pain Albert C. Hergenroeder, MD Pediatrics

Goals The audience will understand the diagnosis and treatment of patellofemoral dysfunction (PFD) in adolescents in a pediatric practice. Pediatrics Page 1 xxx 00. #####. ppt 9/17/2020 9: 08: 04 PM

Objectives The audience will be able to describe, in the context of PFD: 1) What is PFD? 2) Other possible diagnoses 3) The history and PE findings 4) When to obtain imaging 5) Treatment 6) Referral Pediatrics Page 2 xxx 00. #####. ppt 9/17/2020 9: 08 PM

PFD • Overuse injury of the extensor mechanism of the knee, involving the patella as it tracks in the femoral groove, and its retinculum excluding other intraarticular and extraarticular processes. • “Runner’s knee”; “chondromalacia patella”; patellofemoral pain syndrome • Most common cause of knee pain, SM Pediatrics Page 3 xxx 00. #####. ppt 9/17/2020 9: 08: 09 PM

Anatomy Pediatrics Page 4 xxx 00. #####. ppt 9/17/2020 9: 08: 10 PM

Anatomy Pediatrics Page 5 xxx 00. #####. ppt 9/17/2020 9: 08: 10 PM

History • Usually weeks to months • Usually dull, sometimes sharp • Knee may give way ‐ Internal derangement vs. PFD • Often no specific trauma to knee • Other injuries to leg? Pediatrics Page 6 xxx 00. #####. ppt 9/17/2020 9: 08: 11 PM

History (cont’d) • Worse with stairs • Theatre sign • No mechanical complaints: locking • No constitutional complaints • Does not occur at night Pediatrics Page 7 xxx 00. #####. ppt 9/17/2020 9: 08: 12 PM

PE • Where does it hurt? ‐ One finger Pediatrics Page 8 xxx 00. #####. ppt 9/17/2020 9: 08: 12 PM

PE (cont’d) • Biomechanical issues ‐ Pronation ‐ Weak hip rotators – “Bad balance” ‐ Weak quads ‐ Tight hamstrings, and quads • http: //youtube. com/watch? v=Np. W 7 r. SF 1 PXs Pediatrics Page 9 xxx 00. #####. ppt 9/17/2020 9: 08: 13 PM

Differential diagnoses • Infection/Arthritis • Tumor • Referred from hip • Internal derangement of knee ‐ OCD; meniscal tear; ligament tear Pediatrics Page 10 xxx 00. #####. ppt 9/17/2020 9: 08: 14 PM

Differential diagnosis (cont’d) • ITB tendonitis • Pes anserinus bursitis • Patellar subluxation • Internal derangement: meniscal tear Pediatrics Page 11 xxx 00. #####. ppt 9/17/2020 9: 08: 14 PM

Physical exam finding to support patellar subluxation? • Apprehension sign Pediatrics Page 12 xxx 00. #####. ppt 9/17/2020 9: 08: 15 PM

Radiography for chronic knee pain? • Author’s opinion: get plain x-rays (AP, lateral) if: ‐ You are not comfortable with the diagnosis ‐ You cannot reproduce the pain that brought them to the clinic: the chief complaint. ‐ If there are constitutional complaints ‐ If the PE findings are worrisome • Sunrise view for patellar subluxation/dislocation • Tunnel view for OCD Pediatrics Page 13 xxx 00. #####. ppt 9/17/2020 9: 08: 16 PM

Treatment • Rest – relative rest • Ice • Brace – I don’t recommend; if they have one… • Must include a PT consult for ‐ Flexibility • Hamstrings, quads, calves ‐ Strength and endurance: quads, core ‐ May require 1 -2 visits or 2 x/week for 8 weeks Pediatrics Page 14 xxx 00. #####. ppt 9/17/2020 9: 08: 17 PM

Returning after an injury • Premature return increases risk of reinjury • Goal is 100% of baseline strength, flexibility, endurance and proprioception • Once these goals are achieved (~90%) then start functional rehabilitation • Best example, in general, is the walk-jog program Pediatrics Page 15 xxx 00. #####. ppt 9/17/2020 9: 08: 17 PM

Summary • PFD – most common cause of gradual onset knee pain in adolescents • PFD diagnosis can be made on history ‐ Gradual onset of dull knee pain, no systemic complaints, usually no direct trauma, worse with stairs, theatre sign • Corroborated with PE ‐ Tenderness in peripatellar region, no swelling ‐ Limited flexibility, poor core strength: “corkscrew” Pediatrics Page 16 xxx 00. #####. ppt 9/17/2020 9: 08: 18 PM

Summary (cont’d) • X-ray if concerned about diagnosis (initially), mechanical complaints, constitutional complaints, if you cannot reproduce the pain on knee exam (hip) or if no improvement on follow-up • Refer to sports medicine or orthopedic surgery: ‐ Mechanical complaints ‐ Swelling ‐ Failure to improve with treatment ‐ Uncertain diagnosis Pediatrics Page 17 xxx 00. #####. ppt 9/17/2020 9: 08: 19 PM

Summary (cont’d) • Other causes of chronic knee pain ‐ Systemic process ‐ ITB bursitis/tendonitis – lateral ‐ Pes anserinus bursitis – medial ‐ Chronic patellar subluxation – medial • Treatment principles the same Pediatrics Page 18 xxx 00. #####. ppt 9/17/2020 9: 08: 20 PM

Summary (cont’d) • Treatment ‐ Relative rest, ice ‐ PT referral ‐ Return to exercise gradually before returning to sports • Walk jog program Pediatrics Page 19 xxx 00. #####. ppt 9/17/2020 9: 08: 21 PM

Thank you! alberth@bcm. edu Next, Dr. Loud Pediatrics Page 20 xxx 00. #####. ppt 9/17/2020 9: 08: 21 PM