Sports Injuries in the Adolescent Knee

Lora Scott, MD
Primary Care Sports Medicine
Dayton Children’s Hospital
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Sprain = stretching or tearing
of a ligament
Strain = stretching or tearing
of a muscle or tendon
Grade 1 = microscopic
stretching and tearing
Grade 2 = partial tear
Grade 3 = full tear
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Look for swelling, deformity, asymmetry, muscle tone
◦ deformity = your exam is DONE. Send to ED
◦ effusion = possible surgical issue
◦ Low muscle tone = chronic problem
Can raise suspicion for meniscus tear, ACL tear, PFS
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Peripatellar (patellofemoral ligaments) = PFS
Tibial tuberosity – Osgood schlatter
Proximal medial tibia – pes anserine bursitis
Joint lines – meniscus tear
MCL / LCL – sprains
Distal femoral epiphysis – Salter 1 fracture
Patellar tendon / Quadriceps tendon – tendonitis
Lateral knee – IT band
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Lachman and Anterior Drawer – ACL
Posterior Drawer – PCL
Valgus and varus laxity – MCL / LCL sprain
Patellar Grind – PFS, subluxation, dislocation
Dial test – posterior lateral corner sprain
McMurray and Thessaly – meniscus tear
(pictures later)
Hip
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Many adolescents will feel hip
pathology radiating to the thigh or
knee.
Check hip internal / external rotation
Do further eval if exam is painful
Feet
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Pes planus commonly causes knee
pain
No sports.
Surgery usually
required
No sports until
rehab complete.
Surgery needed
in some
circumstances
May continue
sports at
reasonable
levels
At risk for
permanent
disability. Do not
miss.
Drop
Bench
Start
Never draft again.
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Gradual onset, no injury OR
◦ Develops after another injury due to altered mechanics
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Managed with NSAIDs, ice, PT, bracing
Common causes = patellofemoral pain syndrome, OsgoodSchlatter disease, and patellar tendonitis
Uncommon causes = plica syndrome, fat pad impingement,
pes anserine bursitis
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A catch-all term for knee pain related to how the patella
tracks over the femur. Often related to strength and flexibility
issues
Typical history –
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No acute injury.
Peripatellar pain – unable to pinpoint specific location
Pain worse with running, squats, stairs.
Episodes of knee “giving out” after prolonged sitting.
May complain of pain or FB sensation under patella
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Typical physical exam findings
◦ Inspection – normal or slightly atrophied quadricep muscle on affected
side
◦ ROM – Tight hamstrings
◦ Palpation – Tenderness in medial and lateral patellofemoral ligaments
◦ Special joint testing – Positive patellar grind test, weak hip abductors
Treatment
 They CAN continue all sports through the pain without doing
additional damage
 +/- brace
 PT, PT, PT, PT – Should focus on quadriceps strengthening,
hamstring flexibility, hip abductor strengthening.
 +/- Shoe inserts if pes planus present
 Anti-inflammatories (NSAIDs and ice)
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Overuse injury in the patellar tendon or the apophysis at
either end of its attachment
Typical history
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No acute injury
Specific area of pain in anterior knee
Worse with running, jumping, stairs
Increasing difficulty with sports activities
Improves when sitting out of sports, then returns upon re-entry
Typical physical exam findings – in addition to possible PFS findings:
 Inspection – normal or prominent tibial tuberosity.
 ROM – normal, pain with extreme flexion
 Palpation – tenderness at tibial tuberosity (Osgood-Schlatter), distal pole of patella (SindingLarsen-Johansson), or patellar tendon
 Special Joint testing – All normal
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They CAN continue sports on a limited basis.
◦ It IS possible to make this worse, but most kids will stop due to pain
first
◦ No pain meds before practice or games – only after
◦ Stop when pain affects technique or performance
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Patellar strap
PT
NSAIDS, NSAIDS, NSAIDS, ice, ice, ice
Consider immobilization at night x6 weeks
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Impingement and inflammation
of patellar fat pad
Athletes often hypermobile
with hyperextension as
baseline
Treatment = NSAIDs, ice, PT
Knee brace with cut-out often
presses directly on the area of
pain.
Sports OK
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Cause = lining of knee joint becomes
impinged and inflamed. More
inflammation  more impingement 
more inflammation
Most common in runners.
Symptoms similar to PFS
Patients may complain of a popping
sensation with knee flexion /extension.
Peri-patellar popping can be
reproduced on exam with McMurray.
Conservative treatment is NSAIDs, ice,
PT
Aggressive treatment involves
injections, and finally surgery.
OK to continue sports
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Common in swimmers who swim
breaststroke or IM
Gradual onset of worsening pain
located at pes anserine bursa
(proximal medial tibia)
Tender area at pes anserine bursa.
Tight hamstrings
Treatment = NSAIDs, ice, PT.
Injection if no improvement
OK to continue sports
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Tight IT band causes rubbing and
friction along distal lateral femur
Symptoms – Lateral knee pain
with activity, gradual onset, no
injury
PE findings – tight hamstrings,
TTP distal lateral thigh / knee,
tight IT band (Ober’s test), weak
hip abductors
Treatment – PT, NSAIDs, ice
Sports as tolerated
If this patient is unable to touch his left (top) knee to the exam table, it is a
POSITIVE test indicating a tight IT band
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Tight hamstrings or calves
Discoid meniscus
Posterior meniscus tear
Baker’s cyst
Long list of uncommon
problems
Burnout
 Bullying on team
 Not good at sport
 Small for age
 Parents pushing too hard
 Coach pushing too hard
**They need you to be the
bad guy and say they can’t
do sports
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Acute injury causes the patella to stretch or tear its stabilizing
structures.
Patients report the patella “popped out.”
Physical findings
◦ Acute = effusion, decreased ROM, tenderness in peri-patellar
structures, (+) patellar grind, (+) patellar apprehension
◦ Subacute / chronic = same as PFS
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Treatment depends on risk of recurrence (age, activity level,
previous episodes, etc)
Varies from PT, NSAIDs, ice, and stabilizing brace to surgery
Gradual return to sports as pain and stability improve
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Prevents valgus movement at knee
Injured by direct blow to lateral knee, plant and twist
mechanism, or forced valgus against resistance.
Symptoms = pain, swelling, feeling unstable
Can often bear weight with a limp and attempt to continue
playing
◦ Guess what gets hurt next, if knee goes into valgus again?
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Inspection – May have effusion
ROM – normal or limited (depends on acuity, comorbidities,
patient pain threshold)
Strength - normal
Palpation – TTP along MCL
Special testing – MCL laxity
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NSAIDs / ice for swelling
Crutches PRN
MCL brace
PT
Gradual return to activity
Surgery in certain circumstances
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Mirror image of MCL sprain – other side of knee
Can be caused by direct blow or varus stress against
resistance
Slower to heal, higher risk for surgery, higher risk of
comorbidities
MCL sprain from
lateral blow
LCL sprain from
medial blow
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Injury to LCL and additional surrounding structures.
Comorbidities are common and include ACL tear, common
peroneal nerve injury, vascular injury
Can be due to direct blow to anteromedial knee or flexed
varus knee, hyperextension, or total knee dislocation
Treatment varies widely based on extent and duration of
injury
Permanent alteration in knee mechanics for higher grade
sprains which go untreated
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The usual: pain, effusion, decreased ROM,
tenderness over affected area
Special testing = dial test
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Causes = trauma
◦ Severe hyperextension, dislocation, or blow to proximal tibia
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Presentation = unable to walk, effusion, instability (chronic)
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Physical exam = inspection shows
a tibial droop. Special joint testing
shows positive posterior drawer
Diagnosis = MRI
Treatment = crutches, knee
immobilizer, ortho
Outcome = long rehab post-op
(9+ months)
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Causes =
◦ Knee rotates on planted foot, compressing and shearing meniscus OR
◦ Another structure in the knee tears and pulls the meniscus along with
it
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Symptoms – the usual.
◦ Acute = pain, effusion, difficulty with sports and sometimes with ADLs.
◦ Chronic = mechanical (locking, catching), +/- pain
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Physical exam findings
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Effusion, decreased ROM
Tenderness along joint line of affected side
Difficulty with flexion (McMurray can be cruel!)
Consider Thessaly test
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Crutches PRN
NO sports – can worsen tear
See orthopedics
MRI to confirm and diagnose type of tear
Expected recovery time is about 6 weeks after surgery until
back to full sports. Can often return on a limited basis earlier.
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History –
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Acute knee injury
Usually plant / pivot mechanism. Direct blow also possible.
Pt usually NWB after injury
Edema, decreased ROM, diffuse pain
Females during and after adolescent growth spurt at high risk
due to altered mechanics, new center of gravity
Brady Knee Video
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Effusion, decreased ROM,
unable to full extend. May
walk on toes with knee
slightly flexed on affected
side.
May have hamstring spasm
and pain
Positive Lachman >
positive anterior drawer
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Ice, knee immobilizer, crutches – to reduce swelling and
further injury
Start prehab to keep quadriceps engaged
MRI to confirm
Refer to orthopedics
Expected rehab time from post-op to full sports = 6-9
months
I pose 3 questions. If they can answer “yes” to at least 1 of them,
we try to figure out a way to let them play
1. Is the team paying you to play?
2. Will the team pay for your surgery?
3. Is this your last chance to do this sport, ever?
Who might be allowed to play on a badly injured knee?
 Professionals, college scholarship athletes, Olympians, last
game of career
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Distal femur Salter Harris fracture
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OCD lesions
◦ Acute injury, tenderness on distal femoral physis, unable to bear weight
◦ Permanent growth problems in 1/3 of cases
◦ No injury, gradual onset
◦ Normal exam
◦ Seen on x-ray tunnel view
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Knee dislocations  hopefully you never have to see this!!!
EMERGENCY
Hip pathology
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ALL of the above treatment = NWB, crutches, ortho
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◦ Don’t forget to check hip as part of knee exam!!!
◦ May need emergent management