Lecture
Picmonic
A 15-year-old male with knee pain (watch video)
Patient will present as → a 14-year-old boy with left knee pain. He denies any trauma to the knee. The patient runs cross country for his high school team and attends practice regularly. On physical exam, the tibial tubercle is pronounced and there is tenderness to palpation over the affected area. The patient reports pain upon resisted knee extension
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Classically present with tenderness over the tibial tubercle in a 9-14-year-old male who has undergone a rapid growth spurt and doing sports that involve running.
- Repetitive traction of the apophysis of the tibial tuberosity results in microtrauma and micro-avulsion - the proximal patellar tendon insertion separates from the tibial tubercle.
- Pain and swelling over the tibial tubercle at the point of insertion of the patellar tendon.
- Pain on resisted knee extension with lump below the knee and prominent tibial tuberosity.
Diagnosed with lateral radiograph of the knee
- Irregularity and fragmentation of the tibial tubercle.
Benign and self-limiting
- Conservative analgesics, ice, and physical therapy - first-line treatment for Osgood-Schlatter disease.
- Operative - ossicle resection and/or excision of the tibial tuberosity - considered in patients who do not respond to conservative managament and after skeletal maturity.
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Osgood-Schlatter disease involves apophysitis of the proximal tibial tubercle often due to overuse. Active, young boys who have experienced a recent growth spurt and partake in running and jumping activities are most at risk for this condition. Osgood-Schlatter disease is a clinical diagnosis based on history; additional signs and symptoms include anterior knee pain that increases over time, an enlarged tibial tubercle, and localized edema. Since this condition is often self-limiting, treatment is conservative and consists of rest, activity restriction and NSAIDs. |
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Question 1 |
A 13-year-old boy presents to the clinic for a complaint of right knee pain that he first noticed about a year ago. It started out as mild discomfort in the area just below the kneecap, but has been getting progressively worse. Now, it hurts anytime he uses his leg, even when walking. He does not remember any injury to his knee. On examination of his knee there is swelling and exquisite tenderness over the tibial tubercle. Radiographs are normal. What is the most likely diagnosis?
Chondromalacia patellae Hint: Chondromalacia patellae can only be diagnosed under an arthroscopic examination, not on the basis of clinical features. | |
Legg–Calvé–Perthes disease Hint: Legg–Calvé–Perthes disease is avascular necrosis of the proximal femur and usually presents between 4 and 8 years of age. | |
Osgood–Schlatter disease | |
Patellar dislocation Hint: Subluxation of the patella or dislocation is more common in adolescent girls and the patient presents with acute knee pain. The knee is in flexion with a mass lateral to the knee and with absence of the bony prominence of the patella (flat). |
Question 1 Explanation:
Osgood–Schlatter disease is caused by microfractures of the patellar ligament where it inserts into the tibial tubercle. This condition usually occurs in the preteen and adolescent years, and is more common in males than females. The history of injury can be vague and the patient may not remember a specific injury that precipitated the pain. Often, the pain progresses to the point of interference of even routine physical activities. X-rays may or may not show any abnormalities. Upon x-ray, type I disease appears normal, but type II will reveal fragmentation of the tibial tubercle. Often, after healing there will be enlargement of the tibial tubercle. Generally, treatment consists of rest, limitation of activities, and isometric exercises. Chondromalacia patellae can only be diagnosed under an arthroscopic examination, not on the basis of clinical features. Patellofemoral overuse syndrome presents with medial knee pain and subpatellar pain. Additional signs are swelling and crepitus in the knee and it is more common in females than males. It is diagnosed by increased Q-angles (anterosuperior iliac spine through center of patella to tibial tubercle). Subluxation of the patella or dislocation is more common in adolescent girls and the patient presents with acute knee pain. The knee is in flexion with a mass lateral to the knee and with absence of the bony prominence of the patella (flat). X-ray confirms the dislocation. Legg–Calvé–Perthes disease is avascular necrosis of the proximal femur and usually presents between 4 and 8 years of age.
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