A twelve-year-old girl presents with a 4-day history of anterior R knee pain. Her mother reports that her daughter reports it occurs after running, jumping, and walking down stairs. When she sits on the couch or lays in pain the pain subsides.

Physical Exam: Tenderness to palpation over R knee tibial tubercle, mild swelling is present, pain with knee extension, Neg. Lachman’s maneuver, and normal neurovascular exam. DTRs are 2+, lower extremity pulses are 3+.

Radiological results: Superficial ossicle in the patellar tendon. Thickening also viewed of the patellar tendon.

• What are the differentials for consideration?
• What diagnostic evaluations constitute the ongoing assessment of children with this diagnosis?
• What are the acute and chronic complications associated with the child’s condition?
• What treatment plan would you develop for this child?
• What pertinent educational information would you provide the parent (guardian) for the care of this child?

ANSWER

Differentials for Consideration

Osgood-Schlatter Disease: This condition is characterized by pain and tenderness at the tibial tubercle, which worsens with physical activity. It commonly affects adolescents during periods of rapid growth.

Patellar Tendinitis: This condition involves inflammation of the patellar tendon due to overuse or repetitive activities. It can lead to pain, swelling, and tenderness over the patellar tendon.

Patellofemoral Pain Syndrome: This condition is characterized by anterior knee pain, especially with activities like running, jumping, or going downstairs. It is often caused by improper tracking of the patella within the femoral groove.

Apophysitis of the Tibial Tubercle: Similar to Osgood-Schlatter disease, this condition involves inflammation of the tibial tubercle growth plate, leading to pain and tenderness.

Diagnostic Evaluations

Physical Examination: Palpation of the tibial tubercle, assessment of pain with knee extension, and examination for swelling are important in diagnosing this condition.

Imaging: X-rays can reveal an ossicle in the patellar tendon and thickening of the patellar tendon, helping to confirm the diagnosis.

Acute and Chronic Complications

Acute complications may include exacerbation of pain and inflammation if the activities causing stress to the patellar tendon continue. Chronic complications may involve persistence of pain and functional limitations if the condition is not managed appropriately.

Treatment Plan

Activity Modification: Temporary avoidance of activities that exacerbate the pain.

Physical Therapy: Targeted exercises to strengthen the quadriceps and improve patellar tracking.

Pain Management: NSAIDs or other pain relievers to alleviate pain and inflammation.

Bracing or Taping:Techniques to support the patellar tendon and reduce strain.

Educational Information for Parents

Activity Modification: Emphasize the importance of reducing activities that worsen the pain and discomfort.

Physical Therapy: Explain the role of physical therapy in strengthening the muscles around the knee and improving the condition.

Medication Use: Provide guidance on when and how to use over-the-counter pain relievers if necessary.

Follow-up:Advise regular follow-up visits to monitor progress and adjust the treatment plan as needed.

Return to Activity: Discuss the gradual return to normal activities once the pain and discomfort subside.

Conclusion

A comprehensive approach to managing this child’s knee pain involves considering various differentials, conducting appropriate diagnostic evaluations, understanding potential complications, and developing a tailored treatment plan. Educating the parent about the condition and its management is essential for successful outcomes.