Anterior Knee Pain

1
Anterior Knee Pain

• Christopher G. Jarvis, MD, FAAFP
• Fellow, NCC Primary Care Sports Medicine
  Fellowship
• MAJ, MC, USA

2
History

• 13 y/o male basketball player presents to the
  pediatric clinic with c/o increasing anterior
  knee pain over the last 2-3 weeks
• He states that the pain is worse with activities
  like jumping and sprinting and is now causing him
  to limp after practice.

3
Differential Diagnosis

• Osgood Schlatter Apophysitis
• Sinding-Larsen-Johansson Disease
• Infrapatellar Tendinosis
• Osteochondroma
• Bipartite Patella
• Patellofemoral Pain Syndrome
• Osteochondritis Dissecans
• Osteochondral Fracture
• Tibial Tubercle Avulsion Fracture
• Patellar Sleeve Fracture

4
Physical Exam

• Tender, enlarged tibial tubercle
• Tight hamstrings, quadriceps and achilles
• Mild infrapatellar swelling
• Resisted knee extension reproduces pain
• Straight leg raise painless
• Potential extensor lag secondary to pain

5
Diagnostic Studies

• Plain radiographs
• CT/MRI
• Ultrasound

6
X-rays

• normal initially, enlarged, irregular/fragmented
  tibial tuberosity, seperated ossicle (33-50),
  patella alta

7
R/O Avulsion Fractures
8
Ultrasound

• Operator dependent

9
Final Diagnosis

• Osgood Schlatter Apophysiti s clinical
  diagnosis
• 21 of knee pain in athletes, 4.5 in
  non-athletes
• Bilateral in 20-30

10
Treatment/Management

• Reassurance and education
• RICE, NSAIDs
• Relative rest with activity modification (pain as
  tolerated)
• Quad, hamstring, achilles flexibility program
• Patellar sleeve with cutout and inferior
  horseshoe
• Patellar strap (Cho-Pat)

11
Treatment/Management

• Knee/Tibial pad
• Crutches
• Foot Orthosis
• Temporary Immobilization
• Casting
• Surgery
• Resection of ossicle and tendon debridement
• Consultation

12
Return-to-Play

• May require 1-2 years to resolve
• Relative rest with activity modification (pain as
  tolerated)
• 76 dont require activity limitations on
  diagnosis

13
Red Flags/Referral

• Complications
• Avulsion fracture
• Nonunion of the free ossicle
• Patella alta/patellar subluxation
• Premature fusion of the anterior part of the
  proximal tibial physis with resulting genu
  recurvatum
• Consultation
• Uncertain diagnosis
• Failed conservative therapy
• Painful nonunion
• Avulsion fracture

14
Summary

• Pre-teen and early teens affected
• Microtrauma/overuse syndrome
• Clinical diagnosis
• Symptom limited activities
• Conservative treatment most of the time
• May take years to resolve
• Rule out fracture