Medial knee pain

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12 year old football playing boy

presenting with medial knee pain sometimes with 'clicking noise'.

pain from non-weightbearing knee as he brings his foot back to kick the ball.

I could not reproduce the pain, feet over pronating with internal rotation of both knees.

could anyone point me in the correct direction!

so far i have tried to control the pronation (aols) advised on wearing knee support and sent a referral to physio for possible quad excercises

cheers scott

 

This may be plica syndrome. Plica syndrome can cause clicking in the medial knee associated with pain with knee flexion and extension. It can be palpated as a "cord" over the medial femoral condyle with the knee extended or flexed and will generally "snap" over the femoral condyle when the knee is flexed under eccentric quadriceps loading. Treatment consists of reducing running and other ballistic activities, icing and decreasing pronated position of foot. If worse comes to worse, consider a cortisone injection with a sports orthopedist.

 

Hi Kevin,

That sounds about right, i did notice an enlarged area over the medial side of the knee, this maybe the thickening of the plicaee.

never heard of this condition before, you learn something new everyday.

thank you

scott

 

Scott,

The senario you present could actually be the manifistation of hip pathology, specifically a slipped capital femoral epiphysis. He is in the typical age range, and quite commonly it produces medial knee pain while the clinician searches for pathology in the knee. The motion of kicking puts more torque on the hip than the knee. Check it out clincally and get xrays of the hip ASAP.

Nick

 

Nick,

The boy is not overweight, and no abnormalities or discomfort when testing the hip?

thanks scott

 

Scott:

If you want to learn more about plica syndrome, then I suggest you do a web search since there is quite a bit of information on this relatively common condition that occurs in the knees of athletes. Here is one for starters http://www.kneeguru.co.uk/html/steps/step_05_patella/plica.html

 

cheers

 

Scott,

These facts certainly lead us away from the hip. However, not all SCFEs are overweight, nor have significant hip pain. Remember...diseases don't read textbooks. I'd rather miss a diagnosis of plica while fishing for hip pathology, than visa-versa. A simple weightbearing/frogleg xray is all that's needed if things are not moving along. This kid probably doesn't have a SCFE, but it's not the kind of thing you want to miss.

Nick

 

Nick:

Even though I understand your concern of possibly missing a potentially crippling diagnosis, unless this child reports hip pain with walking or running activities, or has hip pain with range of motion or limitation of hip range of motion, then slipped capital femoral epiphysis (SCFE) seems a very unlikely diagnosis. I was always taught that if you hear hoofbeats outside your window, don't think zebras, think horses. I don't know of any orthopedic surgeons that would be thinking of SCFE unless the medial knee pain was also accompanied by hip pain, or hip range of motion problems. Certainly, an orthopedic surgery consult seems in order here if resting the knee doesn't relieve the pain.

 

Hey Kevin,

Once bitten, twice shy.....I had a case of medial knee pain in an 11 yo diagnosed by his pediatrician as a sprain, sent to me for rehab. He had no hip pain whatsoever- never did. I noted his pain had no anatomical basis as it did include the lower portion of the medial thigh. He was unresponsive to care focused on the knee. He was sent to an orthopedic surgeon (unlike the ones you know) who included a hip film in his w/u and the ice cream was sliding off the cone. He needed surgery, and intrestingly during his recovery, the other side began to slip. It was a very odd case.

You are no doubt correct...the case in this thread is most likely not a SCFE, but it does warrant consideration if the pain is unresolved regardless of the hoofbeats.

Horses never trot into the courtroom, only zebras.

Take care

Nick

 

Nick:

That's a good one....I'll need to remember that one.

Also, that was an interesting case history you provided. I can see now where you are coming from.

 

Knee flexion +/- IR/ER should reproduce the pain clinically.

Like Kevin, I wouldn't be considering SCFE; but then again I might have missed one in the past 10 years unknowingly. Is the costs (radiation etc) of radiology low enough to ensure you don't have a low probability condition. Like Kevin stated, surely hip assessment will hightlight some problems.


To me from far away, check the medial (meniscal) joint line (via palpation), and the pes-anserine tendons.

Ron