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Last special topics of the year – let’s make it a good one.
A 12 year old female competitive gymnast presents to your clinic with complaints of left knee pain after she landed a backhand spring in her backyard this past weekend. Her parents decided to take her to you for an initial consult and recommendation for need for any further imaging or consult. She’s very fearful of flexing her knee and presents with an antalgic gait. No bruising or abnormal skeletal deformities present.
What additional information during your subjective and objective clinical evaluation can guide your differential diagnoses? What other factors must you consider with this patient in regards to her age?
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Hi All,
I think I would want to make sure we aren’t missing anything more serious here. I’d inquire about onset of symptoms and if the features fit to warrant knee pain as the structure at fault. Location of pain (both locally or proximally), severity (swelling details, WB details-immediate delayed), progression from time of onset to now, mechanical sx, prior history of LE injury/pain (different? Same but worse?). I’d take a thorough history to inquire about hip or anterior thigh pain. Based on her age I think we have to remember the importance of not missing a stress fracture, or OCD. I think asking about nutritional status, menstruation (started/abnormal?!), history of fractures (idea of bone fragility), recreational demands, and other metabolic or systemic conditions would be important.
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Technically the Pittsburgh Knee Rule says < 12 y/o post-fall or blunt trauma. She’s close enough in age that I would go ahead and send her out for an XR.
I would want to know if she could walk/WB immediately after the fall, any isolated patella/fibular head p!, and see if she is able to bend her knee past 90. If not, I’d recommend an XR ASAP.
Talking to young patients about pain can be challenging, due to their lack of experiences and knowledge. I would love to hear how others communicate with children regarding pain because this is something I struggle with.
We also have to take into account that this kid’s body is constantly changing, growing, and adapting. I would not want to miss a potential fx of a growth plate.
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Cam – Good call about the Pitt and Ottawa Knee Rules, I agree with that. I know the Ottawa Knee Rules aren’t meant for children, but I think she is old enough that they would apply to her. If there are any positives for the Ottawa Rules, I would definitely recommend an XR. If they are all negative, I still may recommend one anyways based on what I find. Her age and demands of her sport and risk factors enough for me to be highly suspicious of a fracture.
Casey – great list. I didn’t think about menstrual stuff but do think that is important to ask.
To add to Casey’s questions: did she land the back handspring well? Was there a twisting MOI? Is this a move she has done 1,000x or is this new to her? Has there been a fast increase in activity level? Is she under stress from parents or coaches to be a specific weight? I’d break out the tuning fork and see what happens.
With kids I do a lot of “show me” rather than asking a bunch of questions because it is hard to get good subjective info from them. The other thing I do is compare to the other side when doing objective testing so that they know what normal is. Lastly, case-by-case basis, but I’ve had some awesome parents who can tell me what hurts and what is abnormal just from seeing their child move now vs. prior to injury. I always try to have parents present at least in the beginning to help with adherence to HEP and to help explain the why we are working on X, Y, and Z and how it’s going to help.
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A case that’s always stuck with me was this 9yo girl with an ACL sprain and no other history of more legitimate injury.
The 9yo remarked “Well, my teacher told me she had the same thing happen to her and the rehab was a lonnnng process and even then the knee was never the same.” She said it so casually.
Pain is a concept built on perspective and experience, so I like to get an idea of any patient’s (esp younger ages) past injury history just to get an idea of how serious this event FEELS to them. I’ve broken bones, and I know there are injuries that just deeply feel like something is very wrong but how it’s expressed is all relative.
It can sometimes be fun to get an idea of the parents’ past injury history to get an idea of the perspective being passed down to the kiddo. Information like that can help guide my recommendation for further imaging and tell me how much I need to educate the parents about this potentially formative moment – especially if this patient (case example) is hesitant to participate in giving me clear, objective information.
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Erik – “pain is a concept built on perspective and experience”, got me thinking a little off topic… I feel that our treatment/management of this younger patient and other adolescents presenting with MSK injuries could have a serious impact on their future perspective (for better/worse) of pain and other injuries. I feel that education is key with this age group, making sure that both they and their parents received a positive message on how to manage and recover from whatever issues they may be presenting with.
To the case I like everyone initial idea to use our CPR (pittsburgh and ottawa) to determine if further imaging would be necessary prior to initiating treatment. Key questions I’d be curious about would be any recollection of knee/hip/LE position during MOI, immediate WB status s/p backhand, knee A/PROM, and palpation. Do her symptoms appear to be “fx quality pain?”. Also I would want to know her experience with gymnastics.. Is that her only sport? How long has she been participating in? What does her training schedule look like? And how many backhand springs has she performed in her lifetime?
As for gaining information, communication could definitely present as a challenge as children are very poor at describing symptoms. I typically attempt to give some examples of activities when I collect subjective information from adolescents and try to piece together some information from the parent if they were present during the injury or to help fill in the blanks from initial onset to initial evaluation. Jeff I like your point of “show me” as we might learn more from them in action after collecting whatever subjective information we can as that may look significantly different from what they portrayed to us. With that being said every adolescent is different some of them are wise beyond their years and are ready to answer all our questions and needs to be approached case-by-case in my experience.
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Matt,
Your questions about her sport history and training schedule — are you thinking like an Over Training Syndrome making her more susceptible to legitimate injury?
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Erik,
Obviously I can not speak for Matt, but I would assume maybe he wants to explore both of these aspects. I know I would.
That being said I think its important to take into account how many times is she loading her LE. Are we talking about one bad landing out or are we talking about 100’s of repetitions of the same activity over and over. Is there a history of pain with this activity or soreness with or after practice? Is the athlete and her parents attributing this new symptom to an acute injury inaccurately? Maybe with more inquiry, maybe mechanism is more a multitude of microtraumas to her leg with this being the landing that took it over the edge? If the mechanism seems less mechanical maybe we do need to look into more psychosocial aspect of her activity level and her training.
I think getting an overall idea of the health of this patient with respect to her training history, schedule (and its relation to LE symptoms), and its relationship with her physical/emotional/social well being would be a huge part of my subjective history taking.
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I agree with everyone’s comments to this point. Taking into account her emotional response to her sx is something that could prove to be both meaningful to her at this time and perhaps shape her perspective of pain in the future. This is something that other healthcare providers, her parents, her friends, and her teachers might or might not be taking into consideration.
It would be interesting to see if her fear of flexion and/or her antalgic gait is purely pain related or related to fear of re-injury. I had the opportunity to work with a 11 year old girl with a hx of lateral patellar dislocation x3 and she would not bend her knee past 20 deg when I first saw her. She truly had no reason of not bending her knee other than fear at the time of IE. She had the ability to reach 130 deg by the end of that session but it took 45 mins to get her there (only with verbal encouragement and various exercises that required knee flexion). Anytime I see a kid that will not move their knee or weight bear I think of this. However, without seeing this pt it is obviously impossible to know if this would be related to her case. The discussion to this point just made me think of this case.
I too believe that an XR is warranted in this case based on the above information (without seeing the pt in person). Getting a detailed subjective of training hx, competition level, skill level, hx of trauma/similar pain, mechanism during the backhand spring, swelling/pain trend, and other questions that were mentioned above would be crucial to determining need of XR and appropriateness of PT.
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