Starting with a review of the joint's complex anatomy, this talk from pediatric orthopedic surgeon and sports medicine specialist Nirav Pandya, MD, delivers insights on determining urgency and getting to a diagnosis when an active child or teen presents with knee discomfort – whether that's agony or a dull ache. Pandya explains the key history questions and physical exam factors that will help both primary and urgent care providers distinguish common knee problems in this population; when to order imaging (and whether a simple X-ray will do); and which therapeutic approaches are effective for conditions ranging from ACL tears to patellofemoral syndrome. Learn about judicious use of bracing, whether injections are appropriate, and how to hold the line when pressured to recommend return-to-play too soon. Bonus: a top-ten list of strategies to promote knee health."
Right, it's up here. OK, um, so what I'll be talking about today is the acute knee, I think, um, one of the things that's really, really critical, um, in terms of understanding this is how do we manage this, uh, you know, when they come to your office or, um, you know, in the more acute setting in the emergency room. So hopefully this talk will kind of give you a framework of how to deal with these injuries, um, and then we'll talk really quickly about some of the more common conditions you'll see and how we kind of address that from an orthopedic perspective. So, In terms of our goals, the things we'll talk about number one are we'll review some basic ne anatomy and function. We'll go over some key history and physical exam findings. Um, we'll talk about treatment principles and some general things you want to do to promote knee health, and then we'll spend just a little bit of time talking about some conditions and treatment because I think it's important to know, OK, what are we talking about when they come from the orthopedic or sports medicine clinic and what are we thinking of in terms of these various conditions such as patellofemo syndrome, patellar instability, meniscus tears and ACL and OCD in lesions. So, some of the key history questions and I think the most important way to differentiate out, is this something that you can just give a week or two, or is this something that you need to get more advanced imaging or refer to us, um, kind of in the clinic setting. So, in general, when someone has insidious and dull pain, not super concerned about it in terms of more of an acute issue versus sharp and traumatic, a very kind of key differentiating point. You'll get a lot of people come and say, hey, my knee's been hurting for 67. Weeks, but I don't really remember anything happening and it's kind of just dull and achy. That's less of a concern than I was playing soccer a week ago. I felt a twist and a pop and it was very, very traumatic. Very diffuse pain is less concerning versus localized pain when patients can take their finger and point to one particular area. Pain before and after sports is less concerning versus if they're having pain when they're loading their knee during sports. So the classic thing is, someone's playing basketball, they're like, look, I feel great when I'm playing, but then it hurts afterwards and it gets better the next day. That's less concerning versus, look, it really, really hurts when I'm playing and sometimes I have to stop. And then, you know, a very basic thing is I like to watch when patients are actually coming in to the um come into the office and they look like they're walking pretty normally versus you see that limp, they maybe have some locking or some kind of instability when they're walking into the, into the office room. So those are all key things that help to differentiate. OK, maybe it's OK to wait for a little bit or maybe showing some exercises to do versus no, we need to work this up a little bit more quickly. Um, and now kind of going through some key history questions. So number one, we want to look at prior injuries. Number 2, you want to get a sense of whether they're an explosive athlete or an endurance athlete. You want to look at the number of teams they're playing or practicing on, um, you want to get a sense of their overall volume, so how many hours per week, miles per week, or any kind of changes in intensity. Um, you wanna look at shoes, inserts, braces, if they're taking any supplements, what kind of nutrition they have, some family history, um, those are all key things you want to look at to get a total sense of their athletic participation. Now, a lot of times the question that I'll get is, well, what's the key physical exam maneuver when someone has an acute knee injury? How do you tell if they have an ACL? How do you tell if they have a meniscus injury? But the key thing I want you all to recognize is that it's really the location of where they're sore will direct you to the injury 99% of the time. So really palpation is really critical when these kids come in. Obviously, you don't want to create more discomfort when this happens, but once again, looking at where their sores is really, really critical. So, if you kind of look at the anatomy of the knee and you're thinking, OK, well, where are they sore? Honestly, where they're sore all of the time is going to lend you to is this potentially a meniscus injury? Is this a muscle injury? Um, is this more of a ligamentous injury? Um, so that's really key. So kind of keeping this knee anatomy picture in mind. And then you kind of think of, OK, well, they're generally sore. What are some of the things that I'm testing in terms of ligaments? I'm looking at my ACL I'm looking at my PCL, the, you know, the MCL, the LCL. So just kinda keeping that anatomy in 9 really can help you kinda differentiate cause it can be very difficult when a kid comes in with a swollen knee and everything's sore and everything's hurt, but if you really concentrate on palpating very specifically in certain areas or we'll talk about some ligament exams you can do as well too, that's gonna be really critical for you, OK? And this is how these various structures look during arthroscopy, which kind of gives you a good clinical correlation. So you can see over there on the, um, on the screen over there, you see your femur kind of at the top of that arthroscopic image, your tibia at the bottom, and then your meniscus in the middle over there. Um, and you can see another view of that meniscus, um, with a little probe that's holding it. And then over there shows you what an ACL looks like arthroscopically. It's a white band of tissue that helps to stabilize it. So it kind of gives you a sense of, OK, here's what a textbook looks like, but how it looks arthroscopically. Now, in terms of the function of the knee joint, and I think this is important in terms of assessing kind of what may be going on. It really is a hinge joint. I mean, I know that's very obvious and it bends a leg and allows for walking, but it experiences a tremendous amount of force. So that's what's important to understand that that's why some kids will come in with kind of this dull, insidious a traumatic pain because they're just overloading their joint, which is a totally different workup than the acute knee injury where there may be a ligament or meniscus tear. Um, and you can see the force of even running is 550% of your body weight. Go upstairs is 346% of your body weight, walking places a tremendous amounts of force across the joint. So it's a joint that's susceptible to experience a lot of force and have discomfort, but it's important to understand how some day to day activities can cause that irritation over a period of time as opposed to the more acute setting, and even standing places a certain degree of force across your joint as well too. Now, in terms of the function of some of the ligaments, so this is all kind of tying together of, OK, how are we going to put together our exam. The ACL, which is something that we worry about the most, we see this tremendously injured a lot in kind of year-round athletes who play a lot of soccer, do basketball and football, and the ACL basically prevents the tibia from moving forward independently of the femur, and it's really important for cutting and pivoting. So in essence, what you're trying to make sure is that you're not getting this tibia moving forward, and that's what your exam is really kind of centered around is trying to figure out if this injury has occurred. The PCL does the exact opposite of the ACL. It's basically preventing the tibia from moving backwards. This is a much less common injury, and typically we only really see this in car accidents. And then your medial and lateral collateral ligaments, they basically prevent the tibia from moving medial or laterally independent of the femur. Once again, you really, if you think of this X-ray now, you're not gonna see that much motion, but that's essentially what you're trying to test and what those ligaments are doing. You're seeing if there's more laxy from one side or the other. Now, the important thing to understand is that sometimes it can be hard to tell what's a normal ACL exam. What's a normal MCL exam? Is, are the bones moving more than, than normal. The key thing you can always do is always compare it to the other side. I think that's really key. Number 2, particularly for the MCL and LCL, you can see if they're sore in that region. Because you're gonna palpate over it. Um, and number 3, it can be very hard. That's where sometimes you may need to get an MRI because if a kid is swollen and painful, they might be guarding. So sometimes if you get kids several weeks out from the injury, you can tell if there's laxity, but it can be hard in the clinic, and that's why sometimes you may need to get an MRI in that acute setting as well too. And then finally the meniscus, that's really the shock absorber and it dissipates force. It's really the cushion inside the knee. And the key thing to understand with the meniscus, we'll talk about this a little bit later is that adults will get degenerative meniscus tears where there's not really an acute injury. They're having some soreness there. It's been going on for several months and then they can have a meniscus tear that occurs in the kind of generally over a period of time. In kids, 99% of the time, there's going to be Some sort of acute traumatic event that leads to a meniscus tear. So typically if kids come in and they're saying my knee's been hurting for 3 months, it doesn't really swell up and they're generally sore in the region of the meniscus. Most of the time, that's not gonna be a meniscus tear because kids don't get these degenerative tears. But if they have an acute injury, then you don't necessarily want to worry about that meniscus. So as I said, the location, the pain is really, really key, and then some of these other maneuvers can add on um to your physical exam and help you differentiate out what may be going on, whether you need to get an X-ray, whether you need to get an MRI, OK? Now, when you're looking at this on an actual patient, this is generally where you're thinking of if you can, if they are comfortable with palpation, what may be injured. So, typically if you're sore in the more anterior part of the knee around the kneecap, that's gonna be patellofemoral issues. If you're sore over the tibial tubercle, it's gonna be Oscar Schlatters. If you're tender more along the meniscus, and that's gonna be more posteriorly, not necessarily anteriorly, then you worry about meniscus tears or ligamentous injuries, and then where your IT band inserts in or where your hamstrings insert in the passerine, those are areas that can get sore as well too. I think the key thing to understand is that typically if patients are having more anterior-based pain, very rarely will meniscus tears give anteriorly based pain. Typically, meniscus tears, which we all worry about on top of ligament injuries, but typically give more discomfort in the midline of the knee or more posteriorly. So that's something key to differentiate out. It also helps to guide whether you're gonna order an MRI or not. And the other thing that's really, really important is looking to see if there's a knee joint effusion. So, in general, kids may come in, they say their knee really, really hurts, but if there's not swelling there, then you're not as worried versus if you see an actual effusion. And some people will say, well, what, you know, how do you differentiate out in a fusion from just general soft tissue swelling? Cause sometimes kids will get really swollen around the patellar tendon but not in the joint. The key thing to recognize is that if it's very hard to see the contours of the patella, then you worry about there being a joint effusion versus if they're just sore very focally over the patellar tendon, which you see a lot in kids, then that may not necessarily be a joint effusion. And in kids, unlike adults, when you see a joint effusion, you have to rule out a structural injury, which means getting an X-ray or an MRI. Adults will get joint swelling for Various reasons, from arthritis, from wear and tear and things like that. We don't necessarily in adults work that up all the time. But in a kid, that means the joint is angry, you're basically indebted to figure out what's going on there and rule out a structural injury. So if you get a very young kid, particularly during ski season, we see a lot of this when kids go up skiing, they hurt their knees. They're 7 to 12, and they, and they have a joint diffusion. Typically, in those cases, you're going to see an ACL or meniscus tear about half the time, or particularly an osteochondral injury. In older kids who get over 13 who have an effusion, typically it's gonna be an ACL injury or a meniscus injury. More commonly an ACL injury, particularly if they give a history of a pot. So, key take on point, if a kid comes in with an effusion or says they had an effusion and come to you a couple of weeks later, definitely get some advanced imaging to rule out a larger structural injury. Other things you want to do physical exam wise, always important to check range of motion if kids have a knee that's locked, that should be a point of concern as opposed to maybe they have a little bit of decreased motion, they can't bend their knee all the way back. A locked knee is once again a concern and you worry about is there a meniscus injury or some piece of cartilage floating around. In terms of the meniscus, some other tests you can do, um, and if you're uncomfortable doing them, not a big deal, but with the meniscus, you can kinda take the leg and kind of rotate the tibia back and forth. That basically rotates the tibia and the femur and basically pushes the meniscus up against the femur. And if there's a tear that will cause some discomfort, and that's called a McMurray's test. For an ACL you can do something called the Lachman's test, which basically is kind of translating the tibia forward while you hold the femur. Um, once again, that can be hard if a kid's really swollen or painful, but if the kid's a little bit more relaxed, you might see some more translation there as compared to the other side. The PCL you literally bend the knee up and try to push it back. Um, and typically, since we don't see PCL injuries in kids, you typically won't have to do this that often, but that you can kind of see in that picture there what happens when you push the tibia back and you will see um that tibia kind of shifting backwards when there's a PCL injury. And the MCL and LCL you basically are stabilizing one part of the leg and then kind of pulling the tibia the other way. And it's a little bit hard to sometimes know laxy when you do this, but if there's an injury there, they'll usually have pain. So sometimes these MCL and LCL tests, if you get pain with those maneuvers, and that could be a sign that that's what's going on. So in general, if a kid comes in with an acute injury or there's an effusion, I always recommend getting an X-ray, even though we're thinking about meniscus, ligaments, soft tissues, always important to rule out a fracture or look to see if there's some sort of underlying issue that could be potentially there from an alignment standpoint or a bone standpoint that could explain what is going on. Even though we think about soft tissue with the acute knee injury, you always want to make sure there's not a fracture there, which is pretty common to be there, uh, particularly in younger kids. And then you want to look at the MRI for soft tissue. Um, and obviously we all know that MRI is gonna show the bone as well too, but I think MRI is really, really key, uh, in terms of differentiating out is there a ligament injury, is there a meniscus injury? Where it also becomes really important is if it's very, very difficult to examine a kid in clinic. So if a 9, 10 or 11 year old comes in, they're painful, they're not letting you examine them. It's OK to get an MRI especially if they're a little bit older, so you don't have to necessarily subject them to anesthesia. It's a great tool to help supplement what your physical exam may be or if there's a limited physical exam, getting an MRI helps to differentiate it out. Now, if a kid comes in with kind of chronic anterior knee pain, they've been having this for 3 months, they haven't done physical therapy. It's OK to try physical therapy first, and the reason why is #1, most likely the MRI is not going to show anything of structural significance. And number 2, especially now with how patients have access to their MRI reports, one of the things is that with an MRI there's always gonna be something that's shown there that's not clinically relevant because an MRI will just pick up pathology. And the difficult situation that you can get in is that an MRI may show something like meniscus inflammation or some cartilage where that has nothing to do with why they're presenting the clinic, but then suddenly you're having to explain to families, well, I've got a meniscus tear, why are you sending me to physical therapy when in fact there's sore somewhere completely else. So, I think it's really key to use MRI judiciously, particularly in patients who have more chronic issues, and only get those MRI's if they haven't responded to treatment as opposed to jumping to it first because then A lot of times it's gonna create a lot of anxiety in the patients, in the family, and unfortunately, they may go seek out someone who's going to quote unquote operate on this. And in the community, there are certain orthopedic surgeons who operate on MRI reports, not necessarily on what they're seeing in front of them clinically, particularly in younger kids. So I think it's important to use that judiciously, particularly using it in the more chronic setting. OK. And this gives you an example of kind of various things we can see on MRI. On the left side of the screen, there is a congenital abnormality with the meniscus, which is the black structure between the femur and tibia. It's called a discoid meniscus where the meniscus is a hockey shape as opposed to being small. That's something that you can see on an MRI. The middle image over there, you see what an ACL tear looks like where there should be a nice black line between the femur and the tibia and you don't see that. That's what an ACL tear looks like. And what a kind of regular meniscus tear looks like is on the right side there, where you see the black triangle between the femur and the tibia, and the kind of the posterior part of it, you see a lot of gray signal that indicates that there's a meniscus tear there. And you can see what a discoid meniscus looks arthroscopically. You can see what an ACL tear looks like uh arthroscopically, we see all the disrupted fibers, um, and you can see there what a meniscus tear looks like as well too. So it kind of helps to correlate the MRI with the imaging findings that we see. OK. So that kind of gives you a sense of what we do in terms of key history questions when you use imaging, um, and what we're looking for from an exam standpoint. Now, in general, what are some of the treatment principles you can use in the office when someone comes in with a knee injury, whether it be acute or chronic. So, I know this is very basic, but it sometimes gets forgotten. Rest, ice, compression, elevation are great in the 1st 48 to 72 hours. So if you get a call on a Saturday and says, hey, you know, so and so hurt their knee, it's swollen, we can't see you till Monday, what they can do. Get that swelling under control cause that's gonna be key regardless of what the injury is. Um, stay off of it if they have crutches or if not, kind of have them limit their weight-bearing, compression and keep that area elevated. That's really the critical part of the 1st 48 hours, no matter how severe the injury is. And then if you do get it, if there is an injury that basically, um, is, you know, kind of comes on and you need to decide based on your workup that maybe they don't need an MRI or maybe this is something that is not acute. Physical therapy is the mainstay for 75% of the things that we see even if there is a structural issue. So, physical therapy is really, really critical and a lot of times we will get kids into our clinic who have come in with, you know, anterior knee pain or things like that and are told to rest. A lot of times the reason why that develops, and we'll talk about this a little bit later, is because they have underlying neuromuscular deficits or Weakness or muscle imbalances that cause them to have pain. So part of the component is not just rest from activities, but it's also addressing some of those structural issues that are not necessarily associated with ligament tears or tendon tears and where physical therapy can be really, really key in helping differentiate those problems. And I think a lot of people, you know, particularly parents feel that physical therapy should just concentrate on strengthening quads and strengthening hamstrings and getting big muscles, when in fact, for a lot of the more chronic issues that we see in terms of anterior knee pain, it's really about developing core strength, because if your core is strong, and they put less pressure across your knee, um, and your balance mechanic. are a lot better. So I think it's just good to know that because a lot of times parents will come in and say, they're doing all this hip stuff for my knee, uh, for my kid's knee. They're not really concentrating on the knee. Why are they doing that? Am I in the wrong physical therapy? And actually, that's the right thing you want to do. It's not necessarily just about developing massive quads or massive hamstrings. It's about looking at how you're dynamically moving, how you're loading your knee, and that's where a lot of core strength comes in. And then in terms of bracing, um, we try to err away from using bracing both in the acute and chronic setting. Now in the acute setting, someone has a swollen knee, you're not sure if they have a fracture, they're having a hard time walking around, then a knee immobilizer is good for a couple of days, but we try to get patients out of a nee immobilizer because it leads to stiffness. Once you've ruled out a fracture. on X-ray, then you don't need that knee immobilizer anymore and then you can go to more of a softer brace uh to help give them some stability, but we want them to get motion and not get stiff, even in the setting of there being a ligament tear, and knee immobilizer just really is concentrating uh them in terms of making sure that they're safe to ambulate around until you've ruled out a fracture. OK. And then there are various other types of braces that are available based on your injury, etc. Um, I think that's something in combination with us with a physical therapist, we can determine, but particularly braces are good as athletes return to play. Um, some athletes will use a brace and not do physical therapy, but I think it's something that can be utilized as part of a comprehensive treatment program, not necessarily in the acute setting in and of itself because it can lead to muscle atrophy and people can kind of start depending on that for stability. OK. OK. And then in general, one of the questions we'll get from parents is that after they've done rehab or maybe they're not done rehab or maybe they're back to playing sports, that should we wear a brace to prevent injury. So the studies have shown except for an immediate postoperative period, braces do not prevent injury. There's some limited studies that say that braces may help in terms of preventing injuries during high-impact sports like downhill skiing, or if there's a very specific diagnosis such as you have patellar mal tracking, but in general, we try to discourage patients from wearing braces once they kind of recover from their injury and more kind of as a prophylactic measure, because it leads to muscle imbalance, it kind of messes up with proprioception. So in general, try to encourage kids to get away from braces, except for a limited period of time. And then sometimes we'll get questions even in our pediatric age group is, can I get an injection? And my general thought with injections in the pediatric and adolescent population is that if you need an injection, that means that you should not be playing. It's different in the adult population where you may have underlying arthritis, you need this to basically work. Very different story than a kid who may have overdone it or has a structural issue. We should not be injecting cortisone in them except in very, very select cases. So this is the adult criteria that is used, even adults only get 3 to 40 a year. But for kids in general, unless there's an underlying rheumatologic condition or something else going on, we should not be injecting them, OK? Um, and there are various other injections that adults will get that you may hear about such as hyaluronic acid, platelet rich plasma, all these other things. The, the injections that we use in the adult population are not just, you know, not necessary for the pediatric population. So in general, discourage injection treatment. Um, in this young population. OK. And I talked a little bit about platelet rich plasma. You hear a lot about professional athletes getting it and theoretically helps to speed up return to play. First of all, there have been no studies in the pediatric population that showed these are actually efficacious. And number 2, once again, an 11 year old does not need to get back to play one week earlier. It's very different in a professional athlete. So once again, Discourage the injections from the get-go and really concentrate on rest, activity modification, physical therapy, and really working on getting this injury to heal on its own. And finally, even though we as orthopedic surgeons will do a lot of the surgeries for these, it's only a small subset of pediatric knee injuries that actually need to go on to surgery. This is particularly ACL tears, large meniscus tears, loose bodies, osteochondral lesions. In general, surgery should be a last resort unless there's a greatly traumatic injury or a patient has failed physical therapy. OK. Now, when an athlete comes in, let's say you've kind of ruled out that larger structural injury that we'll talk about, but they still have knee pain, right? It's patellofemoral syndrome, it's IT band tendonitis, it's Oscarch letters. How do you tell a kid or what should you be telling them in terms of whether they can return to play? So, in general, the general principles when you're, when, when you know that an athlete's not ready, these are more of the kind of like global regardless of diagnosis kind of principles. If they have pain in the affected area after physical activity. Pain during activity, pain during activity that restricts performance or chronic unremitting pain. You want to look at, OK, what category do they go into? Typically, in 3 and 4, you never want to clear anyone to play. 1 and 2 are kind of a little bit more nuanced based on what their diagnosis may be. OK. And then it's also important to look at the emotional mental aspect of this as well too. So even though they may quote unquote say they're not having pain, other soft signs that says that their body is not ready or they're still in that burnout phase include chronic muscle or joint pain elsewhere. They come in for a knee injury but their back's also hurting as well too. Um, there's some personality changes. They're more depressed, they're emotionally not all there. That could be a sign of continued burnout. They have elevated resting heart rate, that's another sign of burnout or the fact that that injury is not necessarily at the point yet to go back to play. Um, kind of more chronic fatigue that is present throughout the day, not necessarily associated with activity, um, and the lack of enthusiasm about sports. I think that's one of the key thing is that If you come in and the kid's like, look, structurally you're ready to go, we're gonna clear you and they're like, really? Like, do I have to go back? That should raise a red flag to you that either #1, they're not enjoying what they're doing because there's burnout present, or number 2 is that they're actually may still have pain, but they're not telling you to that or their parents are pushing them to go back earlier than they want to. So get a sense of that before clearing an athlete. And then another soft sign as well too is that the parents kind of say, look, they're, they're not doing their normal tasks, they're not doing their chores, they're not doing their homework. Yes, that could be normal teenage behavior, but in the context of an injury, that could be a sign that there's still lingering discomfort, or they're burnt out, not ready to go back to sport just quite yet. And then, you know, kind of, let's say, OK, we're ready, structurally they're good, but what are the consequences or can you play through discomfort, right? Cause if you're holding everyone out of sports while they're having discomfort, um, there are a lot of kids are not playing. So there is some degree of discomfort that's OK. So, You have to globally think of, well, what are the consequences of playing through pain. Consequence one, there won't be any structural damage, but the pain may last longer. There's a potentially a minor risk of structural damage, which would be a second group, and the third group is there's a major risk of structural damage if I play through discomfort. So what are the diagnoses that you worry about? Well, the ones that we kind of deal with more frequently are, there's no risk of structural damage, but the pain may last longer. These are typically kids who have dull pain at the beginning or end of activity, but none during activity, and they're not limping. This is patellofemoral syndrome, it's IT band tendinitis, jumpers knee, oscarchlatters. So those are kids where you may have a little bit more of a threshold to say, look, it's OK to play if your pain is a 2 out of 3 level while you're doing physical therapy. We still want to keep you in activity, but make sure it's not getting any worse. Then that second group is the group of patients who may have a minor risk of structural damage. These are ones who kind of have sharp pain, which then goes away as activity goes on, um, and then none during activity. So what are these? These are small meniscus tears, very small MCL or LCL spray, and so that's something that we, from an orthopedic or sports medicine standpoint, kind of help differentiate that out. So if you see that one of us has cleared someone with a small meniscus tear MCL injury to play. Those are typically gonna be your higher level high school athletes who have a short window to kind of play. We typically won't do this for like 1011 or 12 year olds, but there may be select athletes where we tell them, hey, low risk, this is gonna get worse, you might have some discomfort, as long as you understand that risk and it is important for you to play, then we may clear you. And then the major risk of structural damage, these are kids who come in with that swollen, painful knee, um, and really can't do activities, but they're still gonna sometimes these parents will be like, hey, can my kid play? I know he can't walk, but can you play this weekend? Um, and these are obviously your ACL tears and your meniscus tears. So you'll hear stories about people come from some far away where they were cleared to play with their ACL tear and did fine. I mean, just because someone was able to do it is not evidence that you should do it. And really it's about saying no, we're not gonna clear you, we're not gonna write that note that says you can go back and play. OK. And then in general, let's say you, you, you're seeing kids for a well child visit. What are some typical things you can do to promote knee health, OK? So, number one, people, you know, total body flexibility, flexibility is key. A lot of kids will come in, they're super tight, they may be strong but not very flexible, flexibility is key. Um, emphasizing total body strength, not just knee strength, so really working on core is key. Um, avoiding deep squatting activities, so that's a very bad position for your knee. So I always say catchers in baseball, that's like the worst position where you're like sitting there for eight hours, you know, day in and day out, so avoiding deep squatting. I think in general, you know, especially in the primary care setting, we should be encouraging uh appropriate weight loss and good healthy eating habits. Avoiding overuse is really, really critical and the the number that I use to make sure that parents aren't overusing and creating more chronic issues is that Kids should not do more hours per week of a sport than their year and age. So, essentially, if you are 10, you should be doing more, no more than 10 hours of organized sports per week. If you're 1212 hours per week. And there are multiple studies that showing that there's a 75 to 80% elevated injury risk, if you go over that. So, that's a good kind of rule of thumb you can use for your kids, uh, and their parents in terms of how much they should be doing. Um, really emphasizing rest, ice, compression, elevation, acute setting for parents, and some kind of other soft things that are, that are good is that, you know, a lot of times kids come in and they forget to change their shoes when they, they're runners, they're endurance athletes. So in general, if they have shoes, if they've kind of used them for about 300 miles, or that's about 6 months, make sure they get new shoes. Um, and also encourage non-impact cardio activities as a means to kind of cross train. So some kids will think cross training is, well, now I'm gonna go to my personal trainer and do speed work or I'm gonna go with this, you know, play, you know, soccer and do more soccer, you know, um, so you really that swimming, cardio, biking is really, really critical. And then in general, in terms of, you know, in terms of running, it's not even running, it's even just activity in general. You don't want to increase mileage, intensity to volume by more than 10% per week. So kind of important to slowly ramp up activity as kids are getting into an exercise program, OK? And then most importantly, respect your body signals. If something hurts, doesn't feel good, you're not enjoying it, then that's a sign to this young athlete that their knee, needs some rest, and it's better sometimes to take a week of rest rather than trying to push through and then having something drag on for 456 months. Now, what we'll kind of go on to right now and kind of this last portion over here is looking at, you know, some common conditions that we see. So the number one thing we we see all of this patellofemoral syndrome, which is anterior knee pain, OK? So, what is patellofemoral syndrome? What is anterior knee pain? It's a guard of variety of multiple different diagnoses, which can all be referred to, you know, various structural areas. But the take-home point is that it's irritation behind the patella. It's the most common thing that we're gonna see and sometimes kids will come up with acute irritation behind the patella, where chronic stuff is kind of built up over time. And that's due to the, the tremendous amount of force that's across the patellofemoral joint, OK? And why does this occur? It's very simple. It's when this equation gets thrown out of whack. Stress equals load times, times intensity. So when you're doing more load, increase the intensity, that kneecap is gonna get irritated. So whenever a kid comes in, With anterior patellofemoral pain, it's the key thing you wanna ask them is, have you increased your intensity? Have you increased how much you're doing? And most of these kids are gonna say they had and the key component is decreasing that load or intensity and then getting into physical therapy cause the other thing that they have are usually some structural issues that are causing them to put more load on their kneecap. OK? So what will patients complain of? It's they're not usually gonna have trauma, they're gonna have this dull pain, they're gonna say it feels like sandpaper, they're gonna be playing sports all the time, sitting for long periods of time causes discomfort and they're gonna be tender around the patella and key, they're gonna lack flexibility. and core strength. So if you look at the risk factors, typically it's gonna be muscle dysfunction, or flexibility, training overuse, kind of weak core strength. Now, sometimes kids will come in and they'll say, this pain just started 23 days ago, but they won't have swelling, they won't, they won't have really an acute story. I think it's key to kind of get out of the history cause most of them will say, well, yeah, actually my knee did hurt me every now and then and it's kind of been building up and now it's gotten worse. It's very different from an acute knee injury. So, You can have an acute exacerbation of anterior knee pain where it kind of is building up, building up, building up, and then suddenly the knee gets very, very irritated, maybe even gets a little bit of swelling. So don't get fooled into thinking that this can't be anterior knee pain cause it's really, really severe. Anterior knee pain can be very severe, particularly if it goes on for a long period of time. So in general, if they are not getting better with conservative management, it's gone on for several weeks, totally reasonable to get an X-ray to rule out OCD lesions, fractures, etc. But as I mentioned before, you don't need an MRI for this, only if they don't respond to physical therapy. Very few patients don't respond to physical therapy and those that, the ones that aren't responding are typically ones who aren't doing their physical therapy exercises. So once again, very rarely do you need to get an MRI unless they truly have an atypical presentation or they're really not getting better with physical therapy even though they've been doing their exercises. The treatment is decreasing that load, using anti-inflammatories. There's some data that suggests that things like glucosamine and chondroitin orally can help, but I think that's more for the older adolescents and then physical therapy is really gonna concentrate on, OK, let's look at the things that are causing you beyond overuse to. Aggravate your kneecap? Is it a core issue? Is it a strength issue? Do you need inserts in your shoes, etc. really looking at this from a total body perspective. And as I mentioned, a lot of this therapy is gonna concentrate on the core and not on your quads. So that's important to emphasize to patients and families. In terms of bracing, bracing has not been shown to be effective, so a lot of kids will come and say, I got this brace with this knee cut out, I got this strap, not effective telefema syndrome, you don't need it. There are some studies that demonstrate that taping may help. Um, I think that part of it's a placebo effect, but it does help patients and it doesn't necessarily lead to muscle atrophy. So in the short term, sometimes patellar taping techniques that a lot of physical therapists will use can be helpful. And the one only surgical pathology for this in terms of anterior knee pain is that some kids will have something called a lia, which is basically more anterior medial knee pain. Sometimes you'll see it on an MRI. It's about 1 out of every 200 kids who has it. It's a synovial remnant that can cause irritation. You can see it in the picture. And they'll typically um complain of pain as you see in that lower left picture over there. Once again, with those kids, we always will still try physical therapy, but if they come back in and say, look, I have very discreet pain in this area of my kneecap. My knee is locking, I feel like something's rubbing. This group of kids will be that small group of kids that may need surgery. It's super rare. Typically, most kids are gonna have more global pain, but in case if you get a patient and they're saying, oh, the recommendation was to do surgery, say, well, you know, we talked about how anti knee pain never needs surgery. There is a small subset that will complain here and it'll be very specific to this area. OK. The next condition that you'll see a lot of is patellar instability, right? Your kneecap sliding out a joint. It's probably the second most common thing that we'll see, um, in clinic besides anterior knee pain. There's just a tremendous amount of patellar instability that occurs in this population. Um, and it's pretty common. Um, it's more common in the pediatric population, almost 8 times more common in the pediatric population. It's the most common acute knee diagnosis that you're gonna see. Someone's gonna come in with a swollen knee and most likely it's gonna be a patellar dislocation. And it's the second most common cause of having an acute hemoarthrosis in kids, um, that typically necessarily doesn't have like a structural ACL tear or meniscus tear. Typically it's gonna be your adolescence where it's the peak incidence and it's gonna be higher in females, OK. So typically what happens in a patellar dislocation is that the patella is going out laterally, OK? So a lot of people will say, oh, I felt like my kneecap went out medially. That's not actually what's happening. What they're seeing is actually the medialfemoral condyle more prominently because the kneecap is shifted out. But 99% of the time, the kneecap is shifting laterally, OK? Um, the only time it's ever will dislocate immediately if it occurs after a surgery, um, it's not gonna occur in the acute setting, OK? Now, in terms of why this happens, it's really, you know, kind of multiple different fractures. Um, it's understanding the bony part of it because most people have patellar dislocation have some issue in terms of their bone structure that predisposes them to it. It's their lower extremity alignment or it's the shape of their trochleaa. They also will have issues in terms of their muscles, in terms of how their patellar tendon pulls the kneecap, and then they also may have issues with their ligament as well too that helps to keep the kneecap in place. So it's usually a multifactorial issue um that's causing this to occur. So when you think about what's keeping the kneecap in place, you've obviously got your patellar tendon and where that patellar tendon attaches on your tibia is going to drive where the kneecap goes. And the key thing to understand is that when these kids come in, their big issue when they dislocate their kneecap is that they won't be able to extend. The knee because the extension mechanism has been irritated. So the key is you want to get that extension back by decreasing down the inflammation, but some of these kids may have recurrent issues because of how their patellar tendon is basically on their kneecap, predisposes them to have that. OK? So, the key in the kind of the acute setting is differentiating out, OK, is this a one-time event versus someone who has this happened currently, right? So in acute event, you're gonna treat very differently from someone who comes in and says, look, my kneecap slips in and out all the time. I don't really get any swelling, but this is becoming more troublesome, OK. So, generally, these kneecap dislocations are gonna be non-contact twisting injuries. They're gonna say something popped. The direct trauma is really rare. Very rarely does someone get a blow to their kneecap that pushes it out. It's usually because they're twisting or they fell and it happens without contact. There's usually a family history of this happen, usually a mom or dad who's had a kneecap dislocation in the past, so very strong family history and most of these spontaneously reduced. If for whatever reason, you're in the emergency room, you're at a game with, with one of your kids, you're just covering a game and someone's kneecap is dislocated. The key maneuver that will pop it in all the time is you just extend the leg. You're not pushing the kneecap in, you just extend it and the kneecap will magically pop in. So, you know, saving a family a trip to the emergency room to get sedated, to get this reduced, because the further you get off the injury, the harder it is to do it. Just on the field, just straighten the leg out, boom, it'll pop in, they can come to clinic and then get that work up down the road, OK? A physical exam, they're gonna have a large effusion, they may have a block or two range of motion. They can be tender over the medial patella and the lateral formal condyle because what happens when the kneecap dislocates, that's where they're sore, OK? And this gives you a kind of diagrammatic kind of picture of where the pain points are in terms of when a patellar dislocation happens. So before you think of imaging, you want to think, OK, why are we getting this imaging? So, you always, even though someone may sound like a patellar dislocation, you want to rule out a fracture cause sometimes portions of the patellar or femur can come off when they dislocate their patella. You also want to confirm that, especially if they're really swollen, that the kneecap is actually reduced, um, and you want to look for loose bodies. OK. So you can see over here an image of a patellar dislocation, there's actually a chunk off the patella, which you may want to get into clinic a lot sooner than someone who has a chronic dislocation without a fracture. Or sometimes what will happen is chunks of cartilage shouldn't come off. This is an arthroscopic image of a loose body. So once again, even though it may just be a patellar dislocation and they need physical therapy, you do want to get some imaging to rule these things out, OK? So you want to get your standard radiograph uses AP lateral notch and the specific patellar view is this merchant view or sunrise view, which you can see over here, which gets a sense of, OK, is the patella located and is there anything kind of sheared off. And then, you know, in terms of MRIs after dislocation. Um, you know, when they come to our clinic, we typically will order an MRI and I think the reason why we want to do it is, number one, you want to rule out any kind of large piece of cartilage that's floating around, but also, you want to make sure that the kneecap actually did dislocate out and you're not missing an ACL injury or PCL injury because a lot of times people say, look, I felt my kneecap pop out when actually that popping was actually their ACL um and not the patella. So we try to get it particularly just to rule out other injuries that may be there, OK? The initial treatment is ruling out other injuries and knee immobilizer for those first couple of days until you can get that fracture ruled out on X-ray, then you wanna basically get them moving but keep them on crutches. Um, we very rarely will have to do surgery for someone who dislocates out the first time, only if they've got a lung, a large chunk of cartilage floating around, and we need to get that back in place, OK? If they don't have that on MRI, physical therapy, physical therapy, physical therapy, and most people can get back to sports within 4 to 6 weeks, OK? And some people say, well, can we save a second dislocation if we operate on them? Well, actually, the data shows that there's really no difference between surgery and non-surgery for first-time dislocator, and no one wants to get a surgery done. So, totally reasonable for a first-time dislocator unless they have a huge cartilage injury to go down the route of physical therapy, OK? And this has even been shown in randomized controlled trials, really no difference between the two. So in general, what you're trying to do is get the pain and swelling down, restore motion, get that quadriceps muscle going, get the rest of your strength back, and as you progress through this, you can get back to sports. And usually this is a 4 or 6 week process. The kind of the last two I'll, I'll kind of touch on really quickly here, meniscus tears, key as I talked about before, meniscus tears in adults, very different than kids. Kids, you're much more aggressive unless patellar dislocations and operating on them versus adults who have more degenerative injuries. The key thing is differentiated out the acute setting, which is more your kids versus the chronic setting, which is more your adults. Acute injuries are gonna have that acute painful swelling knee, they're gonna have locking and catching. These injuries typically can be associated with a larger ligament injury. They'll have pain with deep squats. Their pains can be more along the posterior joint line, not anteriorly, OK? And the important thing to understand is a lot of times, and this is the flip side, in kids, MRI's will show there may be a meniscus tear there when their history and clinical exam doesn't fit with it. So, in an acute swollen situation, if there's a meniscus tear on MRI, yeah, it's probably real. In kids, if they come in with like chronic knee. for 3 years, they haven't had an acute issue and then the MRI says possible meniscus tear. Very low likelihood that that meniscus tear is actually gonna be there. Sometimes it's blood flow, sometimes it's overcall. Kids don't get these degenerative tears in the absence of an acute injury. OK? So, if you have a meniscus tear, well, what are the treatment options? It's very different than adults. So, you want to fix meniscus tears in younger patients because meniscus tissue doesn't heal on its own for the most part unless it's a very, very small tear. So if it's an acute injury, you're having locking, your severe pain, you're young, you wanna preserve that meniscus cause the further you get out from that acute injury, it's less likely to heal and you're more likely to have chronic issues cause the meniscus doesn't heal back on its own. And then in terms of keeping playing very rarely, like I said, does this happen in kids. Now if you get a 17 or 18 year old who has a small tear, it's been chronic, then maybe they can play, um, and they're older, but the vast majority of meniscus tears in kids will get operated on. OK? Now, the good news for kids is that the vast majority of the tears that do get operated on have good blood supply. So you want to repair it. The reason why you want to repair it is that if you take out meniscus tissue, it doesn't heal, excuse me, it doesn't grow back. So you then you'll have less meniscus, which increases your risk of having arthritis. So the key thing is, it has good blood supply, which most of these tears will, we repair them, which is a 4 to 6 month recovery as opposed to adults who get quote unquote, meniscus surgery all the time. But then they're back on their feet in a week or two. Very different surgery in kids and adults, OK? And what we do during surgery is we literally sew the meniscus back together, OK? Now, very rarely in kids we get these smaller tears where you can just kind of shave things out. This is quote unquote a meniscus clean out that adults will get. Once again, this is typically more degenerative tears, we don't see it in kids and we try to preserve meniscus tissue in kids by repairing it as much as possible. The reason why we wanna do that is that if you don't have meniscus tissue, this is what happens. It leads to early arthritis, um, and you don't wanna go down that route. OK? So aggressive derement, aggressively shaving out a meniscus, very, very bad and kids, and one option we do have is we can do meniscus transplants. If a kid had very traumatic issue, was involved in a car accident, we can put artificial meniscus tissue in. But that's usually the outcomes of meniscus transplants are 10 to 15 year kind of outcomes before they wear away. So you don't want to take out a bunch of meniscus tissue and a 10 year old, have to get a meniscus transplant, and then they're aged 25 and they need a total knee replacement. OK, um, in the interest of time, I'll skip over ACL injuries, um, and want to go over to uh osteochondralal injuries really quick because that's something that you're going to see a lot of, um, let me just slide up up to osteochondral injuries. So, um, the reason why you'll see a lot of osteochondral injuries, it's a, it's a point of concern, um, for a lot of parents and families. They hear about knee pain and they worry about, well, what, what is this OCD lesion? What is this that I potentially may have in the acute setting, OK? So what an OCD lesion is, is when a piece of cartilage and bone detaches from the articular surface, OK? Some of these are traumatic, some of these are developmental, OK? And there are two groups, OK? They're the kids who develop these OCD lesions who have a lot of growth remaining, very good prognosis. Then you have the older adolescent patients whose growth flights are closing, that's a big deal, not as good a prognosis, OK? Just like with meniscus tears, when a kid gets an OCD lesion, the reason we want to treat it is we want to prevent early arthritis, which will lead to chronic pain and impairment, OK? Now, most commonly these OCD lesions occur on the medial femoral condyle. So these kids will come in, they'll have a swollen knee. They're very tender in that region, but they'll say, you know, my knee's been kind of off and on swelling. It gets better, then it gets worse. Um, it's kind of this diffuse pain. I can't really remember an injury, um, and that's what goes on, OK? So, do you typically these patients may have a history of trauma and have more of an acute setting, but some of them may not have trauma and say they have vague, poorly localized knee pain, but they have swelling and that's the key. So unlike other patients who have chronic knee pain where they don't have swelling, it's a swelling that kind of raises your interest that hey, there may be an OCD lesion there and there'll be a lot more stiffer and particularly higher level activity like twisting and cutting will cause them to have discomfort and they're gonna say they may have locking or catching, OK? As I mentioned, fusion, decreased motion, tender over the condyles. Sometimes when you kind of rotate the tibia around, it's gonna cause discomfort, various different maneuvers, but really the key for this is you're gonna see this most of the time on X-ray, OK? Now, in terms of looking at an OCD on an X-ray, and this is why I think X-rays are really important, as you see on the left over there a normal looking X-ray on the right, you see, look, it looks like there's like a loose fragment over there or some lucency. That's what an OCD looks like on X-ray, OK? And then subsequently, then we get an MRI because we're looking to see, look, is this something that may heal on its own or is it a piece that looks like it's starting to fall off? And what we're looking at is if there's fluid behind that lesion, which is basically white signal on the MRI. Now, there's various grading systems, sometimes in that OT lesion. It's the way I like to tell parents it's an area that for some reason genetically have less blood supply and it's softer. So whereas everything else may be hard like a table that is almost like a pin cushion. So it can be grade one soft lesions to really, really bad lesions that are grade 4s where a piece has kind of fallen off, OK? There are various different treatment algorithms for these, but in general, what we're trying to do is to get this area to heal. Now, if you're a younger kid and the piece doesn't appear to be loose, then sometimes just with not walking on it, using crutches, doing physical therapy, you can get these to heal, OK? Now sometimes if you're a little bit older or you don't heal with conservative treatment, then we stimulate blood supply in this area by doing a procedure called drilling. And then sometimes if the piece is been like it's gonna fall off, then we'll fix it. And then a rare cases sometimes what we need to do if a pieces come off, we have to fix the area and do various different procedures to get cartilage to heal, OK? And that could be drilling it, it could be sometimes transferring cartilage or putting artificial cartilage in in kids. We want to avoid that by catching these early. So, just in kind of summary, um, to leave some time for questions. In general, in the acute athletic knee, just understand that the knee has complex anatomy. It's a hinge joint and when you see any disruption of the body's ability to walk or to do the hinge, you need to look for kind of bigger issues. The location of pain is key, particularly in the acute setting, know your anatomy, be very wary of a knee effusion. That's the one you want to work up. That's the one you want to get that MRI, that X-ray on and be a little bit more cautious. Always get the X-rays to look for bone issues and get that MRI for soft tissue. In the very acute setting, do ice inflammation, do your physical therapy, sometimes you can do bracing, avoid injections. These are all things that, that you have at your disposal once you've ruled out that larger structural issue. In general, if an athlete has dull, constant pain, they can push through it a little bit, particularly once you've ruled out structural issues, but that sharp pain, that limp, you want to stop. Um, we didn't talk about ACL injuries, but in general, ACL injuries, we fix these in kids, there's no role for non-operative management, so just kinda keep that point in mind. Meniscus tears in general can be repaired or debrided, but in kids, we want to repair them because meniscus tissue doesn't grow back and they have better blood supply. On an X-ray when a kid comes in with locking or catching look out for that OCD lesion, and there are multiple different treatment options, but the key is to prevent that piece from falling out. And in general, the most common thing that we see is patella femoral syndrome. Just know the patella can be easily irritated for the vast majority of people, it's because they've either increased their load or their intensity, decrease that down, get them into physical therapy, have them keep doing their exercises, and for the most part, you're going to get these kids better and back playing sports. So, thank you. I will um stop sharing right now and um I will uh answer some of the questions that may be in the chat, so.
