Chapters Transcript Video Tender Knees: Keys to Identifying the Causes of Knee Pain in Children Oh, well, thanks everyone um for coming today. Um So my talk will be centered around knee pain in the pediatric patient um when to get concerned. So, really what we're gonna try to do is kind of give you a global approach to knee pain. Um kind of the work up some warning signs and we'll spend a little bit of time at the end talking about um some of the specific uh pathologies you may see just so you have information in terms of how to deal with these things if these diagnosis come into your clinic. Um and how we from the orthopedic standpoint will, will manage a lot of these um kind of issues. So I have no disclosures and the goals of the talk will be kind of uh you know, threefold. Number one, we'll, we'll talk a lot about knee anatomy and function. So I think it's important particularly around the knee to understand what are some of the things we're looking for, particularly in terms of our exam and, and the anatomical areas that can be causes uh for a knee pain in this population. Um We'll then talk about some key history and physical exam findings. Um And then we'll talk about general treatment principles. And I think that's where a lot of the bread and butter of this is, is that many of us know what the diagnosis is or, or, or where the pain may be coming from? But then how do we treat it particularly in terms of determined? Can that kid play? Can he not play? You know, when do they need to come to see an orthopedic surgeon? So some of those kind of various principles, we'll talk a little bit about promoting knee health. I think that's important as well too because um a lot of the things we see in this population, even though we talk, concentrate a lot on meniscus tears, ac L injuries. It's about how to keep kids healthy and strong and active with some basic knee health principles. And then we'll spend a little bit of time talking about some conditions and treatments particularly that you'll see commonly in young athletic kids, we talk about patella femoral syndrome, we'll talk about meniscus tears and then we'll spend a little bit of time at the end talking about AC L injuries and and O CD lesions. So kind of a whirlwind over the next 45 minutes about uh knee pain in in the pediatric and adolescent patient, particularly those who are playing sports. So just a couple of questions to keep in the back of your mind as we're kind of going through this talk. Um, you know, I think that one of the most important things is, you know, when a kid has a knee effusion, what are you worried about? And, you know, people think is it rheumatoid arthritis? Is it osteoarthritis? Is it internal derangement? Is it a muscle tear? Um So kind of keep this question in the back of your mind as we, as we go through the talk. Um, a second question, I think that you should understand particularly since we see a lot of AC L injuries is, you know, what's really true about the AC L? There's a lot of rumors or, or feelings or myths about the AC L. Is it a shock absorber? What does it do anatomically? What does it do in terms of stability in the knee? Um And can kids actually get their AC L done? So it's just some questions to think in the back of your mind. Um As you're going through the AC L portion of the talk and O CD lesions, a lot of people hear about it, they may get an extra report that shows that, that this O CD lesion is present. But what exactly is that? What's the work up of it? And and what is it involved in terms of the need? So, just so kind of more global questions you should think about as we're um as we're progressing through the talk. So I think the first important thing to know is that when a kid comes in, what are some of the key history questions that you want to ask them? Because I think even though it can be sometimes difficult a kid comes in, they say their knee hurts and, and there's some more specific questions you can ask them to get a little bit more of a history. Um, as opposed to them telling you look, my entire knee hurts. I'm not really telling you much information. They're tired anyway because you, they come in after school, what are some more pointed specific questions you can utilize to uh to get some answers from them. So the first thing is differentiating out the the nature of the pain. Is it insidious and dull or is it sharp and traumatic? Is it diffuse or is it more localized, is there pain before and after sports or is it during sport? And is there normal gait versus Lockheed instability and limping? And I say the kind of the options on the left there that are in white, you get a little bit less concerned. It's probably more overuse, kind of more related to just kind of growth. Whereas when kids start having that sharp traumatic pain and they can take their finger and point to a particular area and it bothers them while they're maximally warmed up or they're having mechanical symptoms. That's where you really get worried and say, hey, maybe we need to get an MRI or maybe we need to send you to a specialist to get this looked at a little bit more closely. Other things you want to get a sense of it is. What's their prior injury history? You want to get a good sense of their musculoskeletal history because that can play a role in terms of determining what the next best treatment is. Um, get a sense of what sports they're doing. Is it more of an explosive sport where you're typically going to see more of a potentially traumatic injury like soccer or basketball or is it more an endurance sport? Is this more like cross country? Is it more like track where you may have knee pain that looks like a more of an internal danger type issue when in fact, it's more overuse, get a sense of their actual sports volume. So are they playing on multiple teams or they're practicing multiple days a week and get a sense of how many hours per week they're doing physical activity? And, and the reason why that's important is that once kids get, are basically participating in sports for more hours than their age per week, that's when their injury risk goes significantly up. So if you have a 12 year old and they're doing more than 12 hours a week of organized sports activity, you're gonna have a 3 to 4 fold higher risk of injury. So for a lot of these kids, when they come in with anti knee pain. It's not necessarily getting an MRI or, or diag see where in their patella, their inflammation is. It's really just as simple as saying, look, you need to decrease the volume of activity you're doing and also looking at how they also changed intensity of activity. So a lot of kids may be well below that 12 hour a week kind of limit, but they've gone from two hours of activity to 10 hours a week of activity. And that's where a lot of the injury risk is coming from and get a sense of what shoes inserts or braces that they're wearing. Um, get a sense of medications, supplements, any alternative treatments. Um, and sometimes we forget just to ask about nutrition. A lot of kids are not eating properly. They're, you know, having a lot of energy drinks, like a lot of these various things that can impact their musculoskeletal health that goes beyond their actual sporting activity. Um, get a sense of family history, particularly for, for knee pain as well too. And, you know, getting those kind of pointed questions, we'll get you to the diagnosis about 90% of the time the physical exam, which we'll talk about. Now, we kind of sometimes get you a little bit more information, but usually after you've asked those questions and they kind of told you where things are, you kind of led, led them down a certain path, you'll get a sense of what this injury is, is it more of a traumatic injury? Is this an overuse injury? And what you're worried about in terms of key physical exam maneuvers? I think that the most important thing to understand is that where they hurt on the knee will direct you to the injury, 99% of the time. So as opposed to worrying about, what's the special test to diagnose a meniscus tear? What's the special test to diagnose an MC L versus an LCL? Honestly, where you push on their knee for the vast majority of kids, particularly in their adolescence will direct you to where the injury is. So I always say it's important to kind of understand the anatomy. And if you understand the anatomy around the knee and if they're sore in that area, that's typically where the issue is gonna be the sore on the outside of the it band, which you see a lot in runners, that's more likely gonna be the issue than if they're sore down over where the hamstrings insert on the P. And so getting a good sense of your anatomy, even referring to that book can be really helpful, particularly to elucidate where their soreness is. And then as we get more specific in terms of structural issues, sometimes they'll very be pinpoint tender over certain structures. So they may be tender over their meniscus, they may be tender over their patellar tendon. So I think understanding that internal anatomy as well, to combine with kind of more surface anatomy will help, you know where that injury is. And just for interest, you know what these structures look like. Arthroscopically, I always think it's good to kind of correlate it with what we see when we do arthroscopic procedures. You can see over there on the left side of the screen you've got on the top part there in that arthroscopic image, you've got the femur below, you've got the tibia and that kind of thin wavy white structures, the lateral meniscus. Um Similarly, you're looking at the same part of the knee on the inside part. Um And where our little metal probe is, is pulling on the medial meniscus and these are all non torn uh menis this structure right in the middle there, that kind of white banded structure is what an AC L looks like arthroscopically. Um And that's what the patella feral joint looks like up there. You've got the kneecap uh kind of at the top part and then the, the femur underneath. So kind of great kind of examples of what things look like arthroscopically and what we see uh when we're going in there potentially to do something sly surgically. Now, in terms of the function of the knee joint, I think understanding what some of the stresses are around the knee also can help you figure out like what part of the knee is actually giving them problem. The knee is a hinge joint. It, it allows for walking. You know, like I think it's sometimes going back to the basics are important to understand why does the knee hurt during this activity versus another activity that can help with the anatomy? There's a tremendous amount of force across the knee. So running has 550% of your body weight. So there's a tremendous amount of force around your knee, particularly if the knee or the cartilage is irritated, doing certain activities will cause more aggravation. Going upstairs is very, very painful for the knee. So that's why times at times a lot of kids will come in and say, you know, going up and down stairs really hurts or running really hurts. And there's a, there's kind of a biomechanical reason for why that's the case. And it's figuring out the diagnosis, then lets us then determine, well, how much of this can they tolerate versus how much can they do they need to hold off on. Um, given what their injury actually is and even walking itself has some degree of load as well too. Um, not as much as running or going up downstairs, but there is a significant amount of stress around across the knee when you're walking. Um, even standing as well too. Now, when we get to, you know, kind of knee health in general, then we want to talk about some of the specific ligament injuries that we have and a lot of parents will ask, did my AC L get torn or I got an MRI and my AC L is torn. What does that mean? What's the function of the AC L? And the AC L really prevents the tibia from moving forward, independent of the femur and it helps with cutting and pivoting. So that's the reason why we get really concerned about that, particularly with young athletes. If you don't have a functioning AC L, it's very difficult to do sports activities and also your risk of arthritis over a long period of time gets much higher if you don't have an AC L. And essentially what happens is that, that tibia can move forward from the femur, I mean, not that dramatically, but that's a, what's happening when the AC L is torn. You can imagine even if you're not playing sports, having your femur and tibia shift that way over a long period of time can increase your risk of arthritis. So both short term for sporting activity and long term uh for arthritis are the reasons why we get concerned about the AC L, the PC L. We see less often, it's usually more of an issue in terms of a dashboard injury because what happens is the dashboard in a car when you're in a car accident will hit the tibia and actually shift the tibia posteriorly. So we usually don't see PC L injuries in individuals who aren't involved in some sort of motor vehicle accident, but it's the opposite of the AC L. So basically what it does is prevents the tibia from shifting backwards. And the MC L and LCL play similar roles, but they basically prevent the tibia from moving side to side. You see MC L injuries very frequently during football and soccer season. A lot of times athletes will come in, they'll be very, have a lot of pain on the medial part of their leg. They'll be very swollen. And that typically is some sort of like twisting or planning injury where the AC L is fine, but the MC L and sometimes a little bit more rarely, the LCL will actually get injured and it's really preventing that side to side movement for the tibia in the femur. Ok. Another structure that we'll hear a lot about is the meniscus, what the meniscus does, it's the shock absorber. And if you don't have that cushion, which I like to describe to patients in clinic, if there's a tear in that cushion, then your ability to absorb shock goes down over time. And in the short term, that becomes very painful, it can cause mechanical symptoms as well too. The knee can feel unstable and over the long haul, if you don't have a good solid meniscus, what ends up happening is that cascade of developing arthritis starts, starts happening. So meniscus is very important, particularly for kids who are very, very active. But as I mentioned, the location of where the patient is tender will, will basically direct you to the injury 99% of the time. So here's a nice little schematic and and Maria said, you, you everyone will have access to the slides afterwards, but you kind of can see where individuals are sore is typically where the pathology will be your sore of your tear joint. Usually gonna be more kneecap irritation. If your tender over your tibial tle, it's gonna be Oscar slaughters. Meniscus can be more sore over the joint line. So all these various areas will kind of lead you to the injury. Now, the problem becomes is when you see someone acutely in that day or two after the injury, everything is sore, everything's swollen, it's hard to get an exam on them or you don't have pain, you know, you can't palpate the AC L. So we'll talk about work, but sometimes that's where you need to go to an MRI to see what's going on, particularly where there's been a traumatic injury. So in general, when a kid comes in with a traumatic injury and has fluid in the knee joint, it that to me indicates that the knee joint is angry. This is very different than adults. Adults can get effusions for just from wear and tear from arthritis, from walking too much in general, effusions in pediatric patients weren't further work up. And for me, you, it's the easiest way to tell whether an effusion is present. If you have a hard time seeing the outline of the kneecap, sometimes you get swelling kind of more in the fat pad or in the patellar tendon. But a true effusion is where you just can't see that kneecap very well. Now, in young ki kids who have an effusion, typically it's a pretty even split between AC L tears and meniscus injuries when you get to adolescents and adults. um, it's a little bit more higher rate of AC L injuries, particularly if they remember hearing a pop or had some other traumatic thing. Meniscus tears and Osco osteochondral injuries, which are basically with pieces of bone and cartilage coming off are much rarer. The next thing you want to do after palpating them and seeing kind of, you know, where, you know, kind of where there is an effusion or not, is to check their range of motion, very basic thing, but sometimes where they're so in terms of range of motion can be really telling or if they lack some motion, like they can't get their leg completely straight or they're, you know, feeling poppy and when they move it, that may indicate that there may be some sort of meniscus injury or something loose in the knee joint and some more special maneuvers that sometimes are very hard to do, particularly when a kid comes, it is very painful, but some things you can do if there's several weeks out from the injury, something called the mcmurray's test where you basically flex the knee and rotate the leg. That can be a sign that there may be a meniscus injury. If you're looking for an AC L tear and someone's relaxed, you do something called the Lockman test where you basically bend the knee 30 degrees, you stabilize the femur with one hand and then you basically shift forward the leg on the bottom hand. Um And basically what it, what that means is that there is a, you know that there's disruption of that AC L now that can be hard in a younger kid to know whether the AC L is torn or not. Um particularly because they're guardian or sometimes they feel looser. Then what you do is compared to the other side and a lot of times you'll notice side to side differences. So it's not necessarily how one leg feels. I always test the other side. And if I see some difference in terms of how the two legs feel on that test, that may kind of then urge me or, or indicate to me that they have to get an MRI in the PC L. You basically do the same thing as the Lockman says, but you're actually pushing the leg backwards and you'll basically see the tibia shift backwards. Once again, it's rare to see that in pediatric patients. But something to keep in mind if you have an older adolescent who may have been involved in a car accident. Um And then the same thing with the MC L and the LCL, you basically stabilize the leg and you're basically stressing the tibia in relation to the femur to see if the MC R or LCL is damaged. Now, for a lot of times if you get these positive physical exam maneuvers or you're not sure these kids are gonna go down the route of getting an MRI anyway. But what this does allow you to do that if you're taking care of kids and, and you're at a game or at events and they have an injury, sometimes these exams will let you know particularly if they're not having too much pain. If a kid can go back and play in the game or if they see you in your clinic, they're like, look, everything feels fine, let's monitor you for 7 to 10 days and see how you do. Obviously, if there's a positive exam finding, um then you may need to go down the route of holding them out and getting that MRI. Now in general, in terms of radiographs, I know globally, we all know that radiographs are for bone. I think it's important for parents to understand that even when a kid comes in for a knee injury and all of them want to get an MRI, we still need to look at the bone to make sure. Number one, there's not a fracture there, number two to see if there's any alignment issues that are counting for a knee pain or any anatomical variations. And number three, I think parents also need to understand that a lot of insurance companies, if you're gonna go down the route of getting an MRI will not approve it unless you get an X ray. So part of this is logistical for getting MRI S approved. Part of it as well too is to make sure there aren't bony structures. I'll have 2 to 3 times a year where I have a kid come in who are referred in for an AC L injury. They never got a x-ray, whether they're in the emergency room or somewhere else and they actually have a fracture there. And the reason why they have instability is because the bone is broken. So I always say even though it's rare, you need to roll that fracture out. So you're not then suddenly having a kid walk around with a broken bone and waiting a couple of weeks for an MRI when they, and in fact, all they needed was a cast or they actually needed to get their fracture fixed immediately as opposed to waiting 4 to 5 weeks uh down the road for that MRI to come in. So it's really good for fractures, dislocations. It's really good for noticing alignment. It's really good for seeing if there's any early arthritis, particularly if the kid has autoimmune issues and then if there's any issues in terms of, you know, malignancies, like, even though kids will come in with knee pain, um, and they might be an athlete, you always wanna make sure there isn't something else going on that's causing them to have knee pain, that actually may be more of an oncological process. Once you're pretty certain that there may be some sort of soft tissue injury there and you wanna get an MRI to number one diagnose that and number two diagnose it such that it will change management. I think it's important to get an M RIA. Lot of times par, you know, kid may have a slight MC L injury, they might have a slight LCL injury and you're gonna do physical therapy anyway. And it's not necessarily gonna change management. You don't necessarily need to go down the route of getting an MRI on these kids. I say, tell parents if the MRI is gonna change what we're gonna do, it means it's gonna change when you can return to play. It's gonna mean maybe not physical therapy. It may mean surgery then get that MRI. The issue with getting MRI S particularly young patients is that a lot of things are gonna come up on the MRI that are not clinically significant. There may be some signal in the meniscus that, that the radiologist reads as a meniscus tear but has no issues. There may be some tendonitis that someone gets concerned about. That's really, really important because especially now as parents have access to MRI report, it is even quicker than we do. And we're saying, look, it's ok to play or ok, you don't need to go play or there's something that I'm worried about when they read the MRI report, there can be a lot of questions that come up or concerns about that. So I think it's important to get an MRI, if there's a clinical reason for it, it's gonna change your management, not just in order an MRI, just because parents requested or you're not necessarily sure what's going on even though it may not change their management. Um So just to give you a sense of of kind of what MRI will look like, um You can see there on the left screen there, there's something called a discoid meniscus uh which is basically a thicker looking meniscus. You can see almost, there's like a hockey puck between the femur and tibia. Um In the middle image there, you can see an AC L tear. So where there should have been a black line connecting the femur and tibia, you see just a bunch of gray, that's what an AC L tear looks like on the right side there, you can see the, there's a meniscus tear. And what that basically is shown as is that if you see this kind of black structure, which is the meniscus between the femur and tibia, you see some white in there, that's a tear of the medial meniscus. You can see this is what a discoid meniscus looks like. This is what a torn AC L looks like where you see all the fibers all over the place. Um And on the right side there, you can see what a meniscus tear looks like um with a tear there in the substance of the meniscus as opposed to a nice uh nice looking structure. So you've kind of seen your athletes now you've potentially diagnosed what's going on. You may have an MRI, what are some general principles in terms of determining whether an athlete is or is not ready to return. So what are some warning signs regardless what the pathology is? I mean, obviously you've got an AC L tear, they shouldn't be playing, but for like general knee soreness, general tendonitis issues, then an athlete is not ready to return. So in general, if they have pain in the affected area after physical activity, that may be something that you allow them to potentially play through. As long as the pain is not causing them to limp. If they have pain during activity, that doesn't restrict performance, you may be a little bit more lenient with letting those kids play, particularly if you're a high school level athlete there at the end of their season. But when you start getting the three and four, that's where you don't let kids play pain during activity that restricts performance or chronic unremitting pain even at rest. Ok. So if they're having that chronic pain, it's hurting all the time. You don't want to clear them, you're not giving them a steroid injection to allow them to play. I mean, these are pediatric and adolescent patients. There's, if you're having that degree of pain in your body, your body is telling you there's something larger structurally going on as opposed to an adult who may just have generalized pain and swelling from wear and tear. You gotta hold those kids out and make sure that parents aren't using their principles of how they've been treated when they have any knee issue on their young 1011 or 12 year old athletes. Other things that you're gonna see as well too, that may not be necessarily related to the knee pain itself, but can be signs that that knee pain is causing more global systemic issues. That means they're not ready to return. Um If they've got chronic muscle or joint pain, um personality changes, they have an elevated resting heart rate, they have fatigue. Um There's a lack of enthusiasm about practice or competition or they have difficulty successfully completing usual routines. So all those various things um are, are basically markers that may not necessarily be related to knee pain in general, but how they may manifest that they don't want to play because they're physically dealing with a structural issue. So kind of globally putting this together. So, can my athlete in general, if they have a non surgical diagnosis, can they play through the pain? Ok. So I like to break it down into, they'll have no structural damage, but the pain will last longer. A minor risk of further structural damage if they're playing or a major risk of structural damage. So, in terms of some of the consequences of playing, what are some pathologies that have no strut, there's no structural damage but the pain will last longer. Ok. So that's dull pain at the beginning or end of activity. None during activity. That's usually patella femoral syndrome. It band tendinitis, jumper's knee. Ok. Let's have a high school athlete in who has some sort of structural damage, it might increase the risk a little bit more. Um But we may let them play. Those usually kids have sharp pain at the beginning or end of activity. Um None during activity once they warmed up and they have no limp. Those can be very, very small meniscus tears or some MC L or LCL sprains. And then there's that last group of kids who have a major risk of structural damage if they continue playing. These are ones that have sharp pain, they're limping all the time. These are kids who have AC L tears, they have large meniscus tears, they have O CD lesions. These are things where you get really, really worried about it. So those are the group of individuals that I will not allow to pay no matter how much the parents are basically, um pushing for them. Um, so I think it's important for us to make sure we're counseling parents. It says, look, this is the risk of you playing. We're not gonna clear you to play. I know maybe a professional athlete kind of pushed through and played with this type of injury, but for you as a young athlete, we don't wanna do that. Ok. Uh So I'll pause here for a second. I saw one question in the Q and A. Um So I'll read this question really quickly. It says, um should we primary care docs be ordering a knee X ray prior to Ortho referral? We often don't have access to images just to report if it's a clear place where the child needs to see the specialist. Anyway, should we order the X ray ahead of time or just send the Ortho? Um So I think, you know, as a primary care physician, I think it's um totally reasonable, especially if it's easy to access um them to order the X ray. Um just because it, it cuts down on one step as well too. But if it's one of those things where it's in your office, they have to go to another facility to get an X ray. Um It's totally fine for us to do it because we can, most of us have X ray in our office as well too. Um So totally fine. I think sometimes it gives parents reassurance, at least they've gotten some sort of imaging beforehand, but we're happy to do it in our clinic. Uh Or sometimes what may happen is we may want special views and then um we're reordering x-rays. So um totally reasonable from our standpoint um for us to do it or if it's easy for you to get it done um as well too. And uh one more question here, um, should the child have all four to not clear for play? Um So I think in general for those kids, if they have um any degree of those symptoms, in terms of, uh you know, pain before and after pain, you know, basically the key ones for me are pain during activity that's not getting better, chronic unremitting pain. Um, or, or very sharp pain, you should hold them off. If they essentially have pain that gets better after they've warmed up and there's not any pain afterwards, I'll feel more comfortable clearing those kids to play. Um But if they're having pain during activity, chronic pain or very sharp pain that's causing mechanical symptoms, um then I'll typically hold off, um clearing them to play as well too. Now, in terms of some of the more common pathologies we'll see uh in the last couple of minutes, patellar syndrome is the number one thing that we're all gonna see in clinic. It's a classic anti knee pain. This can be very frustrating to deal with um as a young athlete, um it can be frustrating to deal with um for pediatricians. Um and it can be frustrating for parents. Ok. So what exactly is patellar syndrome? So let me um go here. Ok. So what patella femoral syndrome is, is essentially a fancy way of saying irritation behind the patella. Now, the important thing to understand is that even though it all manifests the patella femoral syndrome, there are multiple different things or pathologies that can cause this. It can be soft tissue issues, it can be cartilage issues, it can be nerve issues. It's kind of a grab bag for irritation around the kneecap. Now, the most common reason why we'll get patellar syndrome is that there's increased load across the kneecap. So a lot of climbing, a lot of going up and down stairs, a lot of squatting. But essentially the reason why this happens in most kids, particularly those who are under 16 is they've kind of gone up in terms of stressing the cartilage behind the kneecap. So what this basically means is that their load is tremendously gone up or their intensity has gone up. So it's usually some combination of this that's causing them to have this. So the classic is the kid hadn't basically done um any kind of degree of activity all summer long, then suddenly they increase their load. So suddenly they're running 40 miles a week for their cross country team they can answer knee pain or when it happened is maybe they've been running 40 miles a week, then suddenly they're doing speed work or they're doing some sort of change in the intensity or how, you know, how fast they're running and then you get more stress across the kneecap and for a runner it's loads distance intensity speed. So if anything goes out, out of whack and you could trade, you know, kind of transfer that over to any other sport, you're gonna get more patellofemoral issues. And so what will patients complain of? They typically won't have any trauma. They're gonna say they have dull pain around the kneecap or deep inside the knee. They'll say it feels like sandpaper underneath the kneecap. They usually are the kids who come in there playing sports all the time. They've got three soccer teams, they're doing gymnastics. They've got a private coach on the weekend. So they're definitely having a lot of wear and tear across their kneecap stairs and sitting for long periods of time will cause discomfort. Um, they'll be tender around the patella. Um And that's typically where the symptoms will be or they may not have tenderness there. They'll just say that look, my kneecap is what, where I feel a lot of the soreness and they'll lack a lot of flexibility and core strength. And that's one of the kind of unifying factors for all these kids that they're growing a lot. They have poor mechanics, they're doing a lot of activity. Um and they tremendously benefit from physical therapy. So if you look for all the risk factor tele femoral syndrome, a lot of it is muscle weakness, poor flexibility and overuse. That's really the classic triad of things that we'll see in this age group. And that's the important thing to let parents know that even though they want the MRI, they want to see if there's some sort of cartilage injury. If they stretch, they work on core strengthening and they decrease down the intensity of activity. All doing that will deal with 90 to 95% of the patella femoral syndrome. So, in general, for kids who come with patella femoral syndrome, if they come, this is the one exception, I would say if they come to our clinic, then we will almost always get X rays on them just to make sure that there isn't anything else going on. But in general, if the kid has a classic kind of story of, I'm playing lots of activities, I'm, you know, playing soccer 12 hours a week, my knee hurts, but I'm still doing it. You don't necessarily need to get that X ray right away in that age group because most of the time they can do physical therapy um or do some exercise or activity modification. If it's still not getting better, then you can go down the imaging route in my clinic. We'll only get an MRI, if they haven't gotten better with conservative treatments. So, I mean, 6 to 12 weeks, either formal physical therapy or home ex exercises and some decrease of activity as well too. And that's the key thing because a lot of times kids will come in, they'll be doing 20 hours of activity a week and I'll say, ok, do your physical therapy. So they still do 20 hours of activity and are doing physical therapy and they come back and they say, why is my knee still hurting? I'll say because you haven't decreased the load because this is an issue in terms of too much load, um and too much intensity and not enough rest. Now, people always ask, is surgery ever indicated for patella femoral syndrome? And the answer is 99% of the time. It's not. There is one pathology called Aleka in rare cases when physical therapy hasn't gotten better. It's where surgery may be indicated for Pelle Femoral syndrome. And this is a very specific type of patella femoral syndrome where basically there's a band of tissue called the Pleco, which is an embryo, em embryo logic remnant, almost like the appendix um in the stomach that basically will cause localized irritation over the medial aspect of the patella. And you can see kind of down there on the lower left diagram where kids will have discomfort, they'll have mechanical symptoms, they'll feel almost a snapping in that area. And if they haven't gotten better with physical therapy, then we'll go in there and actually debris that like out very, very rare. But some kids will have that very focal pain in that area and they'll benefit from surgical intervention for that. And these kids will basically have pain right in that, in the top right screen over there, right in that area there. And it'll hurt particularly between 30 to 60 degrees of flexion. Um And you almost feel a tender cord right there and it's rubbing and causing discomfort. Um I'll stop here and answer another Q and A question um because I feel uncomfortable sending kids to PT without an Ortho visit to establish a diagnosis, um totally reasonable for uh if that's the case. Um I think if you feel um pretty comfortable with a kid who may have kind of generalized anti knee pain, they don't have a traumatic injury, they have pain just around the kneecap and they're still very, very active. Um Then it's totally absolutely reasonable to send that kid to physical therapy for patellofemoral pain. Um It's the most common diagnosis that you're gonna see. So if you have localized patellar pain, no history of trauma, no effusion and they're still doing a lot of their activity, then absolutely reasonable to send them physical therapy. Um even for a short course of six weeks. And the good news is that even if you miss an AC L tear or you miss a meniscus tear nothing is going to get progressively worse in six weeks of physical therapy. So even if you send someone for patella fem syndrome when they're not getting better, and then we get an MRI and there's a meniscus tear. You haven't made anything progressively worse. As long as you're telling kids not to push through pain. That's one of the, the, the good things about the knee joint in general is that the really, really traumatic stuff, the AC L tears, the LCL tears, those things that you worry about kids continue to play are gonna be very, very obvious. But if your kid comes in with a relatively benign exam is having pain around their kneecap and you start with physical therapy, um, you're not gonna, you're not gonna do something detrimental to their knee health, they may not get better and then we get an MRI. So, um, if, if particularly in that a traumatic, um, a traumatic instance, it's totally fine to send them uh to physical therapy before, uh before us, but we're happy to see them as well too. And, uh, one other question in the chat, do MRI S have to be with CB um with contrast? Um So typically, um, all our MRI s, um we do without contrast. Um The only reason we'll use contrast is if we're, it's a kind of a post surgical patient, uh or we're worried more about inflammatory arthritis, but pretty much all our MRI S that we do for the joints can be without contrast, the um kind of the quality of MRI. Now, the three T MRI s are so high um that we typically don't need to get contrast for them. Um And the third question, um right now, is is there any difference in management? Um if you think it is tear syndrome, but there is an effusion. So, um yes. So if you, if there is an effusion and even if you do think it's tele femoral syndrome, then we do get a little bit more worried about. Is it tear syndrome manifesting due to a cartilage injury on the, the patella? So um the that's the group of kids that I will if they come in complaining of that and sometimes these kids may have cartilage injury that kind of develops over a period of time. Those are the kids I first get an MRI in if they have an effusion of patella fem syndrome, uh rather than sending them to physical therapy first if they come into our clinic or sometimes what may happen is kids may have subtle patella instability, which we'll talk about where they're having pain around the kneecap. But it's really because the patella is not tracking well or they're having little instability events and that's the group that I'll get an MRI on first as well too. So we'll talk about patella instability. I think that's the second most common thing that we'll see. Uh particularly for kids who present with pain. And um it's actually pretty common, you know, in the general population, it, it's relatively rare, but if you look in the pediatric population, it's several fold higher. So when I tell my kind of kids, when they're dealing with teller patellar instability, when they're younger, I say, look, if you can make it to adulthood without surgical intervention, you're probably going to normalize and get a little bit more stable as time goes on. Um It's the most common acute knee diagnosis that we see more so than AC L tears, more so than meniscus tears. Most kids with a traumatic injury will have some degree of patella and stability. Um And it's the second most common cause of having, having a large joint effusion. We typically see it right around age 15. Um and females in that general 10 to 17 year old age group is the highest risk. I'd say I see five female patients for every one patient. Uh with patellar instability, I think it's just higher in the female population and it's important to understand the anatomy. Um The patella sits in the trochlear groove in any abnormality. In terms of the bony anatomy or soft tissue around that area is what's gonna cause um the kneecap to kind of dislocate out. So a lot of the patellar instability issues aren't necessarily truly traumatic. Yes, there is a traumatic injury that causes to happen, but very rarely do people have totally normal anatomy and then have a patellar instability event. It's not like you have a normal trachea, normal patella and someone just hits your kneecap and it comes out. Typically you'll have a trochlear groove that may be a little bit more shallow. You have an abnormality patella where your tendon attaches on your tibia may be a little bit off. Um So there are different anatomical areas that may be um a little bit off uh in terms of causing this uh issue to happen. But always, it's important to remember that the patella always dislocates laterally. We'll have patients come in and say, oh, I felt my kneecap go up immediately. Um What they're really seeing is actually their femur uncovered. So it looks like the kneecap went out immediately. But patella dislocations always happen laterally. Ok. And then it's important to understand what's actually causing this to actually happen. And that's where you kind of take a deeper dive in the anatomy. Is there an issue in terms of how your legs align? Is it because your trochlea is too shallow? Um Is it because your muscles the way they attach, mean that where your patella tendon attaches actually more laterally and that actually causes your kneecap to dislocate out or is an issue in terms of your ligament is that ligament that keeps your kneecap in place, the issue in terms of causing you to have patellar dislocation. And once again, it's just important to understand the anatomy because if you know, kind of where they're sore and where their tender can then get down to, ok, what's causing this kneecap to dislocate out and then how will patients manifest? Well, you know, the key thing with the patella is that it, it basically keeps, allows the knee to extend. So if you have someone who has patella instability and they're having difficulty extending their knee, that can be a sign that there's something going on with the patella. And if you have issues in terms of patella cartilage, it can also make it make it difficult to extend the knee out. So all these things are really important in terms of understanding what the function of the patella is and how it's extremely important in terms of knee function in any degree of instability can cause you to have kind of disruptions in terms of knee function down the road. So the key point is that when someone comes with a kneecap dislocation, yet, we in the orthopedic clinic are basically different between someone who's dislocated for the first time and someone who's dislocated multiple times. So generally, in terms of the history, they're gonna have some sort of non contact twisting injury, they're gonna say something popped, ok? Um Direct trauma is very, very rare. Um They're gonna have a family history of kneecap issues. So a lot of people will say, you know, my mother had kneecap issues, my father had kneecap issues. My grandmother had kneecap issues. Like it's very, very common in families to have this as well too. Most patellar dislocations will spontaneously reduce. So they'll feel a pop and it'll come back and it'll happen very, very quickly. So they won't even know that their kneecap came out. But their story makes sense like it actually happened. And if it does actually pop out the weight, usually pops back in is when they straighten their leg out. So if you're ever covering a game on the sideline and you're like, oh my God, someone's kneecap pops out. The easiest way to pop it back in is just to extend the leg out and the kneecap will come right back in. You don't push it back in, you don't have to send them in the, er, just straighten the leg back out on physical exam, they're gonna have an effusion. Um, they're gonna have a block to range of motion and they're gonna be tender over the media patella face set in a lateral fro condyle. Ok. On physical exam, that's where they're gonna be sore, they'll be sore over those areas because what happens when the kneecap pops out, there's someone basically uh pushing, there's basically getting that medial part of the cartilage hitting up against a lateral homo condyle and that's where they're gonna be sore. So if a kid comes in and is sore in those areas, um, they're going to basically, you can think that they have patellar dislocation. And you always want to think why before you get imaging in this population. Ok. So the reason why we always get x rays, even though if it's a very simpler patella dislocation is that sometimes you can fracture your patella when the patella dislocates out. You also wanna make sure the kneecap is back in place, particularly in the acute care setting and you wanna make sure there's nothing loose uh in terms of the patella as well too. So you wanna make sure there aren't any loose bad bodies or other cartilage issues. Ok. So you can see over here there's an X ray where there's a piece of the basically of the patella that's basically come off on that media patella set and that's what a loose body looks like. Um When you're uh when you're kind of looking at that uh from the clinical setting, we want to get basic X rays that basically look at to see where the kneecap is basically centered. Um And this is the best view, it's called a sunrise view where you can basically see if the patella is basically centered in the tr clear groove. Now, for a lot of us, they come to Ortho clinic, we will get an MRI after the first time to tell or dislocation. It's a little bit controversial. The reason why we get that is not necessarily to look at the ligaments and not necessarily to look at the AC L or meniscus is to make sure there isn't a loose body in there because a lot of times what ends up happening is that a piece of cartilage will come out and there'll be a loose fragment basically there that you can't see an X ray. And that's one of the main reasons why um we'll wanna get that fragment basically taken out one of the rare indications while we'll get an MRI. After first time patellar dislocation, we'll also look for other ligament injuries as well too, but really, it's making sure that that loose body is not there. Ok? Typically for an initial treatment of someone with patellar dislocated, uh We wanna rule out other injuries, we want to get them in the immobilizer, we'll get them on crutches and then we generally, I would recommend referring them to Ortho it's not necessarily emergency, but we wanna basically make sure that it is truly a patellar dislocation and they don't need an MRI. We wanna get them in relatively quickly. So we can basically get them moving. You keep that knee I mo in for a little period of time and then you'll basically then try to get them back for those first time dis locators. Um If they have a big piece of cartilage out, that's usually the group that will take them to, to the operating room. Um And if they don't have an injury, then usually that first time patella dislocated will send them to physical therapy. Ok. The good thing to note is that a lot of parents will come in and say, look, can you actually, um, do we need surgery for a first time for tle dislocation? The key thing is that if there isn't a large piece of cartilage, um, in there, we basically won't need to get them the surgery, physical therapy and surgery means no difference. So we typically will get them into physical therapy. Ok? And I think that's key to note that these kids don't need therapy and if they see us and they come back to you and say, why don't we get surgery from the orthopedic surgeon? It's something that they basically be treated conservatively. Ok. So the goals of our management to get the pain and swelling down, restore their motion, get their muscle strength back, normalize their gait and basically get them back to sports. Ok. So now we're gonna go to Meniscus tears and AC L in the last couple of minutes. Ok. So in terms of meniscus tears, um this is something we all worry about. Um, when we are actually, you know, we see these kids come in, parents are concerned about it because we see a lot of meniscus tears in this population. So when, when are you worried about a meniscus tear, what do we actually do? So, the important thing to understand for pediatric patients is that typically the rate of having a meniscus tear that needs surgery is actually pretty low. A lot of kids will be worried about. Did I tear my meniscus? But part of the reason is that in adults, a lot of meniscus tears happen because the meniscus is degenerative, meaning that this wear and tear is built up over a period of time and that meniscus tissue is more likely to tear. It's almost like rotator cuffs. We don't see rotator cuff injuries in kids because the tissue is not degenerative. So, in general, even though a lot of parents will come in and say, look, I'm worried about my kid having a meniscus tear most of the time. It's not. And one of the key things that helps you differentiate out a meniscus tear from say patella femoral syndrome is that when you're palpating on someone's joint, even if they may be sore on the joint line, typically, if they're tender more anteriorly along the joint line, that's more patella femoral syndrome. Typically, meniscus tears will give you tenderness on the posterior part of the joint line. So that's a great way to differentiate it out. In addition, what's also key is that meniscus tears in kids. If they do happen, they'll usually be accompanied by a large effusion. Ok. So once again, kids may come in, they'll say they have knee pain for like 4 to 5 months. They've been playing soccer and the parents are very concerned. They have a meniscus tear very low likelihood they have a meniscus tear. Usually meniscus tears in kids are gonna happen. Number one, in combination with a larger ligament injury or number two, it's happening because they have some sort of congenital issue in terms of the meniscus. So the key thing is that kids usually have acute ones. You're not gonna see chronic meniscus tears, uh, in the pediatric population as frequently, they're gonna have an acute painful swollen knee, they're gonna have locking and catching and it's gonna be associated with some degree of ligament injury. Another thing they'll say is they'll have pain with very deep squats as well too and they'll have posterior joint line pain. So those are really the key things that you'll see in this population, adults will get meniscus tears with a completely benign looking knee and an MRI will show it. But for if they don't have these signs and symptoms and typically they're not gonna have a meniscus tear, ok. Um, it can be very, very hard to differentiate out on MRI, whether the meniscus tear is real or not. So, a lot of times if you have a kid that comes in with a meniscus tear and classically what it will be said, what'll say, particularly if they're the, the, the finding hasn't been read by a pediatric radiologist, they'll say increase signal in the posterior horn of the media of meniscus with a tear. And the reason why this occurs is that kids on their MRI will have a lot more signal or vascularity in that part of the meniscus. And as a result, a lot of times kids will get an MRI report that says they have a meniscus tear when in fact, they came in for your tele feer pain. It's part of the reason why I'm wary to sometimes get MRI S on kids because it's gonna show that finding, particularly if it's being read by a radiologist out in the community who's not pediatric trained. So just keep that in the back of your mind. Pediatric patients don't get posterior horn with meniscus tears, adults do but kids don't. So that's why it's important to, to basically order your MRI S judiciously because you don't want parents concerned about it. And then what you don't want them to do is go down to an adult orthopedic surgeon who may not know that and suddenly they get an operation on a meniscus that's actually normal. Ok. But if you are a rare patient that does actually have a meniscus tear, um then typically what we do is we'll try to fix it in a young population. The reason we want to fix it is because once a meniscus is torn and it doesn't grow back, so you wanna try to preserve as much meniscus as possible. Ok. Now, some kids who may have a chronic tear or have some congenital issue may be able to play with a small chronic tear. But for the vast majority of kids with an acute tear, you wanna fix them. OK? Now what determines whether we shave out the meniscus or fix it is really about the blood flow to the meniscus. So the outside part of the meniscus has great blood flow. So we sew it together. The inside part of the Meniscus where you typically don't see tears in kids has not that good blood flow. And that's a group that we usually trim away. The good news is kids typically don't have tears. We have to trim away a large portion of the meniscus and they won't have issues in terms of arthritis down the road. And what we do during meniscus surgery, we basically just sew the meniscus together if it's a good tear, very rarely do. We have to basically trim the meniscus out. But every now and then you get little flaps of meniscus like you do in this picture. Um, where kids basically don't need a large, extensive repair done, ok? And the reason why we don't want to take too much meniscus out in kids is because meniscus doesn't regrow. And what you don't want to do is then develop them having early arthritis in their thirties and forties. Ok? And there are various other things we can do as well too. If someone's in a car accident or they lose all their men meniscus, we can also put artificial meniscus menis in as well too. But once again, very rare in the pediatric population. So in general, for kids, you get like a meniscus clean out, they're usually back to doing activities and um you know, in a couple weeks for repairs, it can be more like a 4 to 5 month process. So it's just something to keep in mind if the kid does have a meniscus injury. Ok. Um In the last couple of minutes I'll go really quickly through AC L tears here and I'll leave some time open for questions. Um We do see it, we're seeing an increasing epidemic of AC L injuries. Um It's up to 250,000 AC L injuries per year. Pediatric and adolescent patients make up the highest age group of people who have that. There can be various different mechanisms where these occur. The key thing is that you get an acute painful swollen knee, ok? On an MRI you're gonna see disruption of that ligament there. Um It's gonna be very clear. Um and a lot of kids will have this injury and it'll be very obvious to you because they've had a painful swollen knee, they had a traumatic injury. They felt a pop. Ok. And do you need your AC L fixed as a pedia in as a pediatric patient? Absolutely. The traditional sense had been because kids are growing, you shouldn't get their AC L fixed. We've now developed techniques that even allow 67 or eight year olds to get their AC L done without disrupting growth. The key thing is if you don't have an AC L and you don't get surgery when you're seven or eight, you can't do cutting or pivoting activity. So it's very hard to be a kid. So therefore, we've recommended getting AC L surgery done so they can get back to their activities and so that they can protect their cartilage. Ok. And we know that kids who don't get their AC L fixed at a young age will have instability, they'll have swelling, they'll have pain, they'll get degenerative changes. And the same sort of thing will happen is if you take out your meniscus, you don't have a solid AC L, you're gonna get lead down the path to early arthritis. Ok. So in general, we recommend a reconstruction of patients under age 30 recommend them even under age 10. It's rare. But as long as the patient or family can do the post operative rehab, they can handle everything that goes on with a 9 to 12 month recovery. We recommend reconstruction. The real group we don't recommend reconstruction in is if the family and patient aren't ready to undergo all the rehab and activity restrictions afterwards. Ok. And so what we typically do when a kid tears their AC L, it's not an emergency. We usually want to get it done within 6 to 12 weeks after the injury because we want them to have good motion. We want them to get their ability to bear weight back and we want them to have good control. So the kid comes in and tear their AC L and they're like, we're not getting our AC L fixed for 6 to 9 weeks. Why are they waiting on me? We actually want them to wait to ensure that they have good, a good environment for their knee surgery. Basically to get done. Surgery is not an emergency. And just technically what we do during AC L surgery, we're actually reconstructing the AC L. We're not repairing it. So what that means is we're putting a new ligament inside the knee using someone's own tissue. We're not sewing the ends of the AC L back together. Ok? And a lot of times, you know, patients may come here and ask what type of AC L graft should I get? The key thing is that you don't want to use cadaver tissue in this age group because the rate of failure is so much higher than using someone's own tissue. Ok. Um I'll skip over O CD lesions. Um just because of the answers of time. So people can have questions. But in general, what an O CD lesion is, is basically bone and cartilage that is basically come off an individual. It can either be congenital for something someone's born with or a more traumatic injury. It's one of those things you'll see on X ray and I'll show you really quickly here on the X ray. Um You'll see, let me pull up over here, you can see on the MRI, what you'll see is you'll see this basically an area of bone and cartilage. It's weaker. Um, and they'll have tenderness over that area, but I'll kind of skip over this just in interest of time. That's what it looks like on an X ray. Um, it looks like a loose piece of cartilage and bone um that is on there. And if you see that on an X ray, you wanna refer that over to orthopedics, we'll get an Mr and we'll talk about various treatment options. So, um in general kind of summarizing here. So there's time for questions. Um the knee is a hinge joint, it is a very complex anatomy, but the location of pain is key. If you know where things are anatomically and they're so in that area, then you can then subsequently then figure out the best treatment option for them. You always want to be wary of a knee effusion in this population. You want to get X rays for bone and MRI for soft tissue. Um The key thing for treatment options in general, you can rest them, you can do physical therapy, their braces, their injections, things like that. But the key thing for me is decreasing load. I think that's really, really key. If you decrease load, you're gonna promote knee health and make sure that a lot of these overuse injuries aren't present. If they have dull, constant pain, it's ok for them to push through a little bit. But if they have sharp pain or a limp, you wanna stop them. AC L injuries are on the rise. It's obviously the thing that we talk about the most and should be treated to prevent arthritis and instability in terms of meniscus tears. They're rare in the pediatric population. Don't be fooled by some MRI findings, you may get back. But if you do have a pediatric patient that has meniscus tear, we try to repair it because meniscus tissue doesn't grow back and we didn't get to talk about O CD lesions, but there are numerous treatment options for them. The key is if a kid comes in, they have an X ray that says they have an O CD lesion, then you wanna refer it back to us to take care of and of all things. The patella is very, very easily irritated. It's the number one diagnosis we see. So think about that basically that that formula, I thought of anything that increases load or intensity. Identify that. If you drop those areas back down, you're gonna have less likelihood of these kids kind of have more discomfort and pain down the road. Created by
