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Posted: February 28th, 2022
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?
Assessing Musculoskeletal Pain: Knee
Patient Initials: MA Age: 15 years Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): “My knees hurt, panful and with clicking sound. I experience catching sensation under the patella. ” The additional history will be assessed by asking questions related to the onset of the pain in terms of acute or gradual, duration of the pain and its associated symptoms and previous treatment for the pain.
History of Present Illness (HPI): MA is a high school sophomore who came to the doctor complaining of knee pain. He is an active basketball player for his school team. He started experiencing knee pain in the last week. He claims to be suffering clicking sounds from both knees.
Location: bilateral knees.
Onset: Eight days while playing basketball.
Character: Dull intermittent pain.
Associated signs and symptoms: A catching sensation under kneecaps.
Timing: For the past 8 dyas.
Exacerbating/ relieving factors: gets worst while patient treks to school. The pain subsides with mediciation rest and ice pack.
Severity: 7 on a pain scale of 1-10 after pain medication Ibuprofen 200mg 2 tabs orally was taken and 10/10 worst pain level after a trek to school.
Medication: Ibuprofen.
Allergies: No allergy to medication but allergic to shellfish.
Past Medical History (PMH): The patient sprained his left knee four months ago, and history of Rheumatic fever during his early childhood.
Past Surgical History (PSH): No history of medical surgery.
Sexual/Reproductive History: None. The patient is not sexually active.
Personal/Social History: Denies smoking, drinking alcohol, or using any other drugs.
Immunization History: All immunizations are up to date as per the parents. Received flu vaccine 10/5/19.
Significant Family History: MA lives with his parents. Both grandfathers have diabetes, his mother is obese. His two other siblings are healthy. The family has a history of obesity.
Review of Systems: MA has presented a complaint of dull knee pain that he experiences in both knees. The pain is clicking and accompanied with a catching sensation under the patella. The pain mostly persists during physical activity.
OBJECTIVE DATA:
General: MA is a healthy 15 years old who has maintained a healthy body. MA is alert and oriented and very active in school when it comes to basketball and running. No complaint of pain in other joints.
HEENT: He denies headache or any sign syncope. Denies loss of vision, has no hearing loss and last visited dentist two months ago.
RESPIRATORY: MN denies a cough and shortness of breath.
Cardiac: No irregular heart rate noted
Extremities: Both knees show no sign of edema and tenderness, but the knees are slightly misaligned with the thigh bone.
Physical Exam: Vital signs: BP 112/72, P 76, regular, T 98.6 temporal, RR 18, and regular. His current weight is 165. Height 5 feet 8inch.
Cardiovascular/Peripheral Vascular: Heart rate is regular and has good S1, S2; no S3 or S4; no murmur. There is no pedal edema or erythema.
Genitourinary: No abnormalities reported with frequencies urination
Psychiatric: The patient appears to be alert and oriented x3. Denies depressive mode
Neurologic: Alert and oriented to persons, place, and time.
Skin: Skin is intact and is warm to touch and appears moist.
Hematologic: No evidence of clotting conditions reported.
Allergic/Immunologic: Allergy to shellfish.
Manual Muscle Testing: Knee flexion 5/5, pain. Knee extension 5/5, painful. Knee ER 5/5, Knee IR 5/5.
Musculoskeletal Tests: The patient can perform a regular activity such as walking, bending the knee with slight discomfort noted.
Diagnostic tests: Computerized tomography (CT) scan, Bilateral Knee X-ray, CBC, and Magnetic resonance imaging (MRI).
The practitioner must assess for abnormalities during musculosketal examination. The lower extremities must be examined for alignment with the edge between the femur and tibia under 15 degrees (Ball, Dains, Flynn, Solomon, and Stewart, 2015 – Research Paper Writing Help Service). Range of motion must be assessed in patients with suspected fracture (Ball et al., 2015 – Research Paper Writing Help Service). McMurray test to rule out tear of the meniscus, Varus-valgus stress test to check for knee stability, and Lachman test for anterior cruciate ligament. The three diagnostic test will help to examine the tissues around the knee, check for patella abnormalities or dislocation, and rule out knee fracture.
ASSESSMENT/Differential Diagnosis:
Priority diagnosis would be Osgood Schlatter Disease: A common cause of knee pain in adolescents. This in an inflammation underneath the knee where the ligament from the patellar tendon attaches to the tibia.
Differential Dx: These include
Osteogenic Sarcoma – This condition is associated with people age 10-25 yrs, and it is characterized by intermittent pain (Ryan, Maryam, & Hue, 2016: 2024 – Do my homework – Help write my assignment online).
Patellar dislocation. This condition is associated with shifting of the knee patella from its normal positioning and is characterized by pain in the patella (Rudavsky & Cook, 2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay)
Patella fracture. The condition is where the kneecap suffers breakage or cracking and result to pain in the knee, accompanied by swelling and bruising around the knee (Reinking, 2016: 2024 – Do my homework – Help write my assignment online). Though the patient does not have all these symptoms, it is a probability.
Medial meniscus- This condition is associated with knee pain, difficulty flexing, clicking, or catching of the knee movement, just like in the case of the patient (Wu et al. 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online).
Patellar chondromalacia. This is when the cartilage in the kneecap gets worn by age or injury and is accompanied by discomfort of the inner knee and pain that aggravate from the physical activity just like in the case of the patient (Pak, Lee, & Lee, 2013).
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015 – Research Paper Writing Help Service). Seidel’s guide to
physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Rudavsky, A., & Cook, J. (January 01, 2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay). Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy, 60, 3, 122-129.
Reinking, M. F. (January 01, 2016: 2024 – Do my homework – Help write my assignment online). Current concepts in the treatment of patellar tendinopathy. International Journal of Sports Physical Therapy, 11, 6, 854-866.
Pak, J., Lee, J. H., & Lee, S. H. (January 01, 2013). A novel biological approach to treat chondromalacia patellae. Plos One, 8, 5.
Wu, J. L., Lee, C. H., Yang, C. T., Chang, C. M., Li, G., Cheng, C. K., Chen, C. H., Lai, Y. S. (January 01, 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Novel technique for repairing posterior medial meniscus root tears using porcine knees and biomechanical study. Plos One, 13, 2.
Ryan, A. D., Maryam, M., & Hue, H. L. (December 01, 2016: 2024 – Do my homework – Help write my assignment online). Review of Osteosarcoma and Current Management. Rheumatology and Therapy, 3, 2, 221-243.
REPLY QUOTE EMAIL AUTHOR
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Here is a 1000-word article on the case of knee pain presented:
Assessing Musculoskeletal Knee Pain in Adolescents
Introduction
Knee pain is a common musculoskeletal complaint seen in adolescents. Proper evaluation and diagnosis are important to determine the underlying cause and guide appropriate treatment. This case report examines the assessment process for a 15-year-old male presenting with bilateral knee pain, clicking, and catching sensations.
Case Presentation
The patient, MA, is a 15-year-old male who presented with 8 days of dull, intermittent knee pain exacerbated by physical activity such as walking to school. He reported clicking sounds from both knees along with a catching sensation under the kneecaps. MA plays basketball and first noticed the pain one week ago while playing. He takes over-the-counter ibuprofen with some relief. On examination, his knees showed no swelling or deformity but slight misalignment. Range of motion was full but painful. Special tests elicited pain.
Differential Diagnosis
Based on the history and physical exam findings, key considerations in MA’s differential diagnosis include Osgood Schlatter disease, Sinding-Larsen-Johansson syndrome, osteochondritis dissecans, and medial meniscus tear (Pak, Lee, & Lee, 2013; Rudavsky & Cook, 2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay; Reinking, 2016: 2024 – Do my homework – Help write my assignment online; Wu et al., 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online).
Osgood Schlatter disease is inflammation at the tibial tuberosity insertion site of the patellar tendon, common in active adolescents. Sinding-Larsen-Johansson syndrome similarly involves inferior patellar pole avulsion injuries. Osteochondritis dissecans involves cartilage and subchondral bone lesions of the knee. Medial meniscus tears can cause catching, clicking, and pain with activity (Wu et al., 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online).
Evaluation and Diagnosis
To further evaluate MA’s knee pain differential diagnoses, additional history was obtained. No prior injuries or treatments were reported. His family history was positive for obesity and diabetes. On physical exam, special tests like McMurray’s reproduced his catching sensation, suggesting possible meniscal pathology.
Radiographs were obtained first to evaluate for bony abnormalities like osteochondritis dissecans lesions or avulsion fractures. MA’s x-rays were unremarkable. An MRI was then ordered due to the persistent mechanical symptoms of catching and clicking. The MRI revealed a tear of the posterior horn of the medial meniscus.
Treatment and Management
Nonsurgical treatment was initially recommended due to the acute nature of MA’s meniscal tear. This included activity modification, bracing, and physical therapy focused on quadriceps strengthening and patellofemoral joint mobilization. Over-the-counter anti-inflammatories provided some relief.
If conservative measures failed to improve his symptoms after 6 weeks, arthroscopic partial meniscectomy surgery would be considered. Postoperative rehabilitation would focus on regaining full range of motion and muscle function before returning to sports. Prognosis is generally good with resolution of symptoms in 80-90% of cases with nonsurgical or surgical treatment (Wu et al., 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online).
Conclusion
This case highlights the importance of systematically evaluating knee pain in adolescents. Careful history and physical exam helped formulate the differential diagnosis in MA, which was then narrowed by selective use of imaging studies. Nonsurgical treatment was initiated first due to the acute nature of his MRI-confirmed medial meniscus tear. Close follow-up will monitor his response to conservative management.
References:
Pak, J., Lee, J. H., & Lee, S. H. (2013). A novel biological approach to treat chondromalacia patellae. Plos One, 8(5). https://doi.org/10.1371/journal.pone.0064402
Rudavsky, A., & Cook, J. (2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay). Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy, 60(3), 122–129. https://doi.org/10.1016/j.jphys.2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay.06.004
Reinking, M. F. (2016: 2024 – Do my homework – Help write my assignment online). Current concepts in the treatment of patellar tendinopathy. International Journal of Sports Physical Therapy, 11(6), 854–866.
Wu, J. L., Lee, C. H., Yang, C. T., Chang, C. M., Li, G., Cheng, C. K., Chen, C. H., & Lai, Y. S. (2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Novel technique for repairing posterior medial meniscus root tears using porcine knees and biomechanical study. PLoS ONE, 13(2). https://doi.org/10.1371/journal.pone.0192371
Additional history needed:
Onset of pain (sudden or gradual)
Activities that exacerbate pain
Previous treatments tried
Family history of similar conditions
Categories of knee pain:
Traumatic – due to injury or overuse
Nontraumatic – degenerative, inflammatory
Differential diagnoses:
Osgood Schlatter disease
Sinding-Larsen-Johansson syndrome
Osteochondritis dissecans
Medial/lateral meniscus tear
Patellofemoral pain syndrome
Prepatellar bursitis
Iliotibial band syndrome
Patellar tendinitis
Infrapatellar fat pad impingement
Bone bruise/contusion
Physical exam:
Inspection for swelling, deformity
Palpation for points of tenderness
Range of motion assessment
Lachman test for ACL integrity
McMurray test for meniscus tear
Apley compression test for meniscus/ligament injury
Structures assessed:
Patella
Tibiofemoral joint
Medial/lateral meniscus
Ligaments
Tendons
Bones
Special tests:
Clarke’s sign
Noble’s compression test
Thessaly test
Based on the history of pain with activity and clicking/catching, key considerations for this patient include Osgood Schlatter disease, Sinding-Larsen-Johansson syndrome, osteochondritis dissecans, and medial meniscus tear. Radiographs and MRI would help further evaluate the possibility of bone/cartilage abnormalities.
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