A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain

Assessing Musculoskeletal Pain

Case 3: Knee Pain

A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?

With regard to the case study you were assigned:

·         Review this week\\\’s Learning Resources, and consider the insights they provide about the case study.

·         Consider what history would be necessary to collect from the patient in the case study you were assigned.

·         Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\\\’s condition. How would the results be used to make a diagnosis?

·         Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient\\\’s differential diagnosis and justify why you selected each.

Expert Answer and Explanation

Knee Pain Episodic/Focused SOAP Note

Patient Information:

JD is a 15-year-old African American Male.

S.

CC “Dull pain in both knees for four days.”

HPI: JD is a 15-year-old African American Male who came to the hospital with complaints of dull pain in his both knees for the three days. He reports that he sometimes feels catching sensation under the patella and both knees often click. The pain started after playing basketball tournament three days ago. He has not applied any medication. The severity of the pain I 8/10.

Current Medications: No medications

Allergies: No allergies.

PMHx: No history of major medical conditions. Pneumonia and influenza vaccines are up to date.
Soc Hx: Denies tobacco or alcohol use. He is the only child in a middle-class family. He loves playing basketball.

Fam Hx: He is the only child in a family of three. Both parents are alive and healthy. Grandfather died of depression. He committed suicide. Grandmother is alive as has type II diabetes.

ROS:

GENERAL:  No fatigue, weight loss, or fever.

HEENT:  Eyes:  No vision problems. Ears, Nose, Throat:  No hearing problem, sneezing, runny nose, congestion, or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR: No heart problems.

RESPIRATORY:  No breathing problems.

MUSCULOSKELETAL:  Knee pain.

HEMATOLOGIC:  No anemia or bleeding.

O.

Physical exam:

Constitutional: General Appearance: Healthy adult with moderate distress. A+O+3, mucous membranes moist, flushed, answers questions properly. Vitals: BP 122/90; P 57; R 20; T 36.3; W 58kgs; H 157cm.

HEENT: Head: NC/AT. Eyes:  Pupils are PERRL, extraocular movements intact; conjunctivae pink. Ears: Hearing intact, normal external appearance. Nose: Appears normal, clear mucus. Mouth: The are in good shape. Throat: No lesions or inflammation of the tonsils.

Skin: Normal color for ethnicity, dry, warm, with no rashes or lesions.

Cardiovascular: S1, S2 with regular rhythm and rate. No heart sounds.

Lungs: Chest walls symmetric. Lungs clear and bilateral. Regular respirations.

Knee: MRI shows ACL tear in both knees.

Diagnostic results: Diagnosis for knee musculoskeletal can be done using MRI or X-ray (Ball et al., 2019). The authors note that X-ray cannot see the ligaments, and in this case, MRI is recommended.

1. X-ray: Pending
2. MRI: Pending

A.

Differential Diagnoses

1. Anterior Cruciate Ligament (ACL) Injury. The primary diagnosis for this ACL injury. ACL injury is a sprain or tear ACL, one of the major ligaments in the knee (Korakakis et al., 2019). The injury occurs mostly in sportspersons. The disease causes pain in the knee. It has been included as the primary diagnosis because the patient is a sportsperson and recently got injured during a game.
2. Knee locking: Characteristics of knee locking include catching sensation, swelling of the affected knee, and pain with extension (Lee, Nixion, Chandratreya & Murray, 2017). The disease is not a primary diagnosis because the patient is no swelling in the knee.
3. Osteochondritis Dissecans: OCD is a joint condition that occurs when blood is not enough in the end of the bone. It also causes pain in the knee, and that is why it has been included in the diagnosis.
4. Juvenile idiopathic arthritis: JIA is the swelling of the joints. The disease occurs before a kid reaches 16 years (Ramanan et al., 2017). It causes joint pain, and that is why it has been included in the diagnosis.
5. Repeated kneecap dislocation: Repeated patellar subluxation is the continued instability of the patellar, which causes knee pain.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel\’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Korakakis, V., Saretsky, M., Whiteley, R., Azzopardi, M. C., Klauznicer, J., Itani, A., … & Malliaropoulos, N. (2019). Translation into modern standard Arabic, cross-cultural adaptation and psychometric properties’ evaluation of the Lower Extremity Functional Scale (LEFS) in Arabic-speaking athletes with Anterior Cruciate Ligament (ACL) injury. PloS one, 14(6), e0217791. https://doi.org/10.1371/journal.pone.0217791

Lee, P. Y. F., Nixion, A., Chandratreya, A., & Murray, J. M. (2017). Synovial plica syndrome of the knee: a commonly overlooked cause of anterior knee pain. The Surgery Journal, 3(1), e9. doi: 10.1055/s-0037-1598047

Ramanan, A. V., Dick, A. D., Jones, A. P., McKay, A., Williamson, P. R., Compeyrot-Lacassagne, S., … & Beresford, M. W. (2017). Adalimumab plus methotrexate for uveitis in juvenile idiopathic arthritis. New England Journal of Medicine, 376(17), 1637-1646. https://www.nejm.org/doi/full/10.1056/NEJMoa1614160

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FAQs

Osgood-schlatter disease

Osgood-Schlatter disease is a common condition that affects adolescents who are going through growth spurts. It is characterized by pain and swelling at the front of the knee, just below the kneecap, where the patellar tendon attaches to the shinbone (tibia). This area may also feel tender to the touch, and may be accompanied by a visible bump.

The condition is caused by repeated stress on the patellar tendon, which connects the kneecap to the shinbone. During growth spurts, bones and muscles may grow at different rates, which can create tension on the tendon. This tension can cause small injuries to the tendon where it attaches to the shinbone, leading to inflammation and pain.

Osgood-Schlatter disease typically occurs in active adolescents who participate in sports that involve running, jumping, or other high-impact activities. Treatment typically involves rest, ice, and anti-inflammatory medication to reduce pain and swelling. In more severe cases, a knee brace or crutches may be necessary to alleviate pressure on the affected area. In most cases, the condition resolves on its own with time and conservative treatment, although symptoms may persist for several months or even years.

The most common symptoms of Osgood-Schlatter disease include:

1. Knee pain: The main symptom of Osgood-Schlatter disease is pain in the knee, especially during activity. The pain is typically located just below the kneecap, at the top of the shinbone.
2. Swelling: The affected area may become swollen and tender to the touch.
3. Bump: A visible bump may form just below the kneecap, where the patellar tendon attaches to the shinbone.
4. Stiffness: The knee may feel stiff or tight, especially after periods of inactivity.
5. Limited range of motion: The affected knee may be difficult to fully bend or straighten.
6. Worsening symptoms with activity: Symptoms typically worsen with physical activity, especially running, jumping, or other high-impact activities.

If your child is experiencing any of these symptoms, it is important to seek medical attention from a healthcare provider or sports medicine specialist. Early diagnosis and treatment can help prevent the condition from worsening and improve outcomes.

Patellofemoral pain syndrome

Patellofemoral pain syndrome, also known as runner’s knee, is a common condition characterized by pain and discomfort in the front of the knee, specifically around the kneecap (patella) and the groove in the thigh bone (femur) where the patella rests. This pain may be sharp or dull and is often aggravated by activities that involve bending the knee, such as running, jumping, or climbing stairs.

The exact cause of patellofemoral pain syndrome is not well understood, but it is believed to be related to a number of factors, including overuse, muscle imbalances, structural abnormalities, and biomechanical issues. Some common risk factors include:

1. Overuse: Participating in activities that involve repetitive knee bending or impact, such as running, jumping, or cycling, can increase the risk of developing patellofemoral pain syndrome.
2. Muscle imbalances: Weakness or tightness in certain muscles, such as the quadriceps or hip muscles, can affect the alignment and movement of the patella, leading to pain and discomfort.
3. Structural abnormalities: Issues such as flat feet, a high arch, or misaligned leg bones can alter the way weight is distributed through the knee joint and contribute to patellofemoral pain syndrome.
4. Biomechanical issues: Poor running or jumping technique, as well as improper footwear, can increase the risk of developing patellofemoral pain syndrome.

Treatment for patellofemoral pain syndrome typically involves a combination of rest, physical therapy, and pain management. Your healthcare provider may recommend exercises to strengthen and stretch the muscles around the knee, as well as modifications to your activity level or technique. Non-steroidal anti-inflammatory drugs (NSAIDs) may be prescribed to manage pain and inflammation. In some cases, bracing or taping may be recommended to help support the knee joint. Surgical intervention is rarely necessary.