Osgood-Schlatter disease is a common cause of knee pain at the insertion of the patellar tendon on the tibial tubercle. The stress from a contracting quadriceps muscle is transmitted through the developing tibial tubercle, which can cause a microfracture or partial avulsion fracture in the ossification center. It usually occurs after a growth spurt and is more common in boys. The age at onset is typically 11 years for girls and 13 to 14 years for boys.
Patients will present with pain during and after activity as well as have tenderness and local swelling over the tibial tubercle. Radiographs may be necessary to rule out infection, tumor, or avulsion fracture.
Rest and activity modification are paramount for treatment. Pain control medications and icing may be helpful. Lower extremity flexibility and strengthening exercise programs are important. Some patients may require immobilization. The course is usually benign, but symptoms frequently last 1 to 2 years. Complications can include bony enlargement of the tibial tubercle and avulsion fracture of the tibial tubercle.
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The patellofemoral joint is a complex joint that dependson a balance between restraining ligaments of the patella,muscular forces around the knee, and alignment for normalfunction. The interior surface of the patella has a V-shapedbottom that moves through a matching groove in the femurcalled the trochlea. When the knee is flexed, the patellarligaments and the majority of the muscular forces pullingthrough the quadriceps tendon move the patella in a lateraldirection. The vastus medialis muscle counteracts the lateral motion, pulling the patella toward the midline. Problemswith function of this joint usually result in anterior kneepain.
Idiopathic anterior knee pain is a common complaint inadolescents. It is particularly prevalent in adolescent femaleathletes. Previously, this was referred to as chondromalaciaof the patella, but this term is incorrect as the joint surfacesof the patella are normal. It is now known as patellofemoral pain syndrome (PFPS). The patient will present withanterior knee pain that worsens with activity, going up anddown stairs, and soreness after sitting in one position for an extended time. There is usually no associated swelling.The patient may complain of a grinding sensation underthe kneecap. Palpating and compressing the patellofemoral joint with the knee extended elicits pain. Patients oftenhave weak hip musculature or poor flexibility in the lower extremities. Radiographs are rarely helpful but may be indicated to rule out other diagnoses such as osteochondritisdissecans.
Treatment is focused on correcting the biomechanical problems that are causing the pain. This is usually done using an exercise program emphasizing hip girdle and vastus medialis strengthening with lower extremity flexibility. Anti-inflammatory medication, ice, and activity modifications may also be helpful. Persistent cases should be referred to an orthopedic or sports medicine specialist.
One must exclude recurrent patellar subluxation and dislocation when evaluating a patient with PFPS. Acute traumatic dislocation will usually cause significant disability and weight bearing seen in an initial dislocation. Patients with recurrent dislocations often have associated ligamentous laxity, genu valgum, and femoral anteversion. The initial treatment is nonoperative and may involve a brief period of immobilization, followed by an aggressive physical therapy program designed to strengthen the quadriceps and improve function of the patellofemoral joint. Continued subluxation or recurrent dislocation is failure of this treatment plan, and surgical repair is usually necessary.
In newborns and non–weight-bearing infants, the difference between posturing and deformity is important. Posturing is the habitual position in which the infant holds the foot; passive range of motion is normal. Deformity produces an appearance similar to posturing, but passive motion is restricted. Most pediatric foot disorders are painless. Foot pain is more common in older children (Table 201-1).
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In-Toeing, Out-Toeing, and Toe-Walking