Selected Podcast
Pediatric Knee Issues
Knee injuries are not uncommon for children and teens. Dr. Jeffrey Mikutis discusses common knee injuries and recovery from those injuries.
Featuring:
Jeffrey Mikutis, DO
Jeff Mikutis is a pediatric orthopaedic surgeon at Dayton Children's Hospital. Dr. Mikutis earned his Doctor of Osteopathic Medicine degree frorn the University of New England College of Osteopathic Medicine; interned at Malcolm Grow USAF Medical Center/Walter Reed Army Medical Center, Washington, DC; completed his orthopaedic residency at the Texas College of Osteopathic Medicine and his fellowship in pediatric orthopaedics at Nemours Children's Clinic/University of Florida. He currently works with residents from Wright State University's Boonshoft School of Medicine, Grandview Hospital and Largo Medical Center. Dr. Mikutis is a retired USAF Colonel who served as an Orthopaedic and Flight Surgeon and is a Fellow of the American Osteopathic Academy of Orthopaedics. Transcription:
Bill Klaproth (Host): Knee pain and injury is a common problem in children and adolescents because the knee is such a complex joint with many moving parts. Here to talk with us about pediatric knee pain is Dr. Jeffrey Mikutis, a Pediatric Orthopedic Surgeon at Dayton Children’s Hospital. Dr. Mikutis, thank you so much for your time today. For a physician listening — obviously, they see a lot of knee injuries, but maybe not remembering the pathophysiology like you do, so can you give us a review of the different types of knee ligament injuries or the ones you see most commonly?
Dr. Jeffrey Mikutis (Guest): Good morning. Yes, we have been seeing an increasing number of pediatric ACL injuries, particularly females greater than males. Also, we see a lot of patellar dislocations in the same genders and in the same age groups. I would say those are the predominate, major injuries that we see in pediatric knee injuries. Now, the physician who evaluates pediatric knee injury also needs to be aware that there are open growth plates as opposed to an adult knee. In the event that there is a swollen knee after an injury, you can’t forget about examining the growth plate, and X-raying the knee, and looking at the growth plate — and even getting an MRI to rule out a growth plate fracture.
Host: Well, that’s a really interesting — and you mentioned that you’re seeing an increase in these types of injuries. Why do you think that is?
Dr. Mikutis: Well, we’re seeing a lot more kids playing sports year-round. I think there is a larger number of females playing today formally. Because of more female participation it correlates with a higher number of female knee injuries because of their higher participation. I think in general, it’s more kids playing more sports, single sport athletes, kids not giving themselves a break. There is an overuse component and a fatigue component that may make them more susceptible to an injury.
Host: And that does make it more challenging for the physician because you were talking about growth plates and being very careful in treating these injuries to prevent long-term damage. What do you want other physicians to know about treating common injuries and keeping the growth plates in mind?
Dr. Mikutis: I think one of the most important things is — and we’re trying to do at Dayton Children’s — is to make sure the kids are conditioned for their sport. We have a program of ACL prevention that is invaluable for female athletes, in particular. I think we need to emphasize kids overall should not be playing a single sport all year round. They need to have a break, and they should be playing multiple sports. For instance, basketball in the Winter, soccer in the Spring, baseball in the Summer, so they’re just not essentially wearing out their body and making themselves susceptible to these injuries.
Host: So, just playing one sport leads to those overuse injuries? And you were mentioning ACL, so when it comes to severe injuries like ACL what do you want other physicians to know about ACL protocols?
Dr. Mikutis: We see a number of ACL injuries in our practice, and as we discussed, the ideal situation would be to have everybody participate — and particularly females — participate in ACL prevention programs. Once we see someone with an ACL injury it is a catastrophic event for them because they’re going to be out of sports for the time period of about a year between doing physical therapy before they have ACL surgery, then undergoing the surgery, then participating in post-ACL rehab, which can involve rehab that can encompass 9- to 12-months.
Host: So, an impact like you said can be catastrophic for a young athlete, and certainly, with an adolescent an injury may impact growth — or growth might impact rehabilitation. And for a growing athlete that’s a huge difference in recovery and return to play as you were referencing. What is your best advice then, for a physician listening on when return to play is safe?
Dr. Mikutis: We are involved with our physical therapists as far as determining when the patient can return to sports. That’s after an operative or a non-operative injury. We closely collaborate with the physical therapists as to when the patient is optimally able to return to sports. That involves a number of physical evaluations and physical therapy that the patient should be able to complete. For instance, strength testing and comparing the injured leg to the uninjured leg. Their injured leg should be within 10 to 20% of the strength of the opposite side, and then should be able to do agility tests that are commensurate with their sports activity. In other words, we have the physical therapist run them through drills similar to what they’d be doing on, for instance, a soccer field. We physically know that they can complete these tasks even with the physical exhaustion and their knee holds out. I think the take-home message here is that we leave a lot to the physical therapists because they’re the experts in that field and are able to assess as to when the patient can return to sports.
Host: And transitioning away from sports for a minute, what about other causes of knee pain, such as referred pain from the hip or even tumor, infection, and even inflammatory arthritis. What would another physician need to know about those causes of knee pain?
Dr. Mikutis: Well, when we teach our residents and when we provide educational conferences, we always emphasize that whenever a pediatric patient, especially in the adolescent period, is complaining of knee pain it’s compulsory to examine the hip because hip pain can be referred down into the knee. One of the entities that we are looking for is a slipped capital femoral epiphysis that can masquerade as knee pathology. That is essential to do. Other things that we very commonly see are anterior knee pain or patellar-femoral pain that can be unrelated to trauma. It can be pretty debilitating and typically requires pretty exhaustive physical therapy to alleviate the discomfort or at least to allow the patient to get back to activities.
Other things that we think about if the patient has a big, swollen knee without any trauma you have to think about some type of inflammatory arthritis. Of course, if the patient presents acutely with a swollen knee and is sick you have to absolutely rule out a septic arthritis. Occasionally, we’ll see the patient who just presents to the office with a swollen either painless or mildly painful knee, and we have to think about other types of things like juvenile idiopathic arthritis. Another entity that we need to think about a lot more today — and it used to be kind of peculiar to the East Coast – is Lyme disease. I always entertain that diagnosis when I see a patient with a painless, swollen knee. That’s one of the rule outs in a swollen knee.
Host: Great information, Dr. Mikutis. And thank you for sharing that with us. We really appreciate your time today. For more information, visit ChildrensDayton.org, that’s ChildrensDayton.org. I’m Bill Klaproth. Thanks for listening.
Bill Klaproth (Host): Knee pain and injury is a common problem in children and adolescents because the knee is such a complex joint with many moving parts. Here to talk with us about pediatric knee pain is Dr. Jeffrey Mikutis, a Pediatric Orthopedic Surgeon at Dayton Children’s Hospital. Dr. Mikutis, thank you so much for your time today. For a physician listening — obviously, they see a lot of knee injuries, but maybe not remembering the pathophysiology like you do, so can you give us a review of the different types of knee ligament injuries or the ones you see most commonly?
Dr. Jeffrey Mikutis (Guest): Good morning. Yes, we have been seeing an increasing number of pediatric ACL injuries, particularly females greater than males. Also, we see a lot of patellar dislocations in the same genders and in the same age groups. I would say those are the predominate, major injuries that we see in pediatric knee injuries. Now, the physician who evaluates pediatric knee injury also needs to be aware that there are open growth plates as opposed to an adult knee. In the event that there is a swollen knee after an injury, you can’t forget about examining the growth plate, and X-raying the knee, and looking at the growth plate — and even getting an MRI to rule out a growth plate fracture.
Host: Well, that’s a really interesting — and you mentioned that you’re seeing an increase in these types of injuries. Why do you think that is?
Dr. Mikutis: Well, we’re seeing a lot more kids playing sports year-round. I think there is a larger number of females playing today formally. Because of more female participation it correlates with a higher number of female knee injuries because of their higher participation. I think in general, it’s more kids playing more sports, single sport athletes, kids not giving themselves a break. There is an overuse component and a fatigue component that may make them more susceptible to an injury.
Host: And that does make it more challenging for the physician because you were talking about growth plates and being very careful in treating these injuries to prevent long-term damage. What do you want other physicians to know about treating common injuries and keeping the growth plates in mind?
Dr. Mikutis: I think one of the most important things is — and we’re trying to do at Dayton Children’s — is to make sure the kids are conditioned for their sport. We have a program of ACL prevention that is invaluable for female athletes, in particular. I think we need to emphasize kids overall should not be playing a single sport all year round. They need to have a break, and they should be playing multiple sports. For instance, basketball in the Winter, soccer in the Spring, baseball in the Summer, so they’re just not essentially wearing out their body and making themselves susceptible to these injuries.
Host: So, just playing one sport leads to those overuse injuries? And you were mentioning ACL, so when it comes to severe injuries like ACL what do you want other physicians to know about ACL protocols?
Dr. Mikutis: We see a number of ACL injuries in our practice, and as we discussed, the ideal situation would be to have everybody participate — and particularly females — participate in ACL prevention programs. Once we see someone with an ACL injury it is a catastrophic event for them because they’re going to be out of sports for the time period of about a year between doing physical therapy before they have ACL surgery, then undergoing the surgery, then participating in post-ACL rehab, which can involve rehab that can encompass 9- to 12-months.
Host: So, an impact like you said can be catastrophic for a young athlete, and certainly, with an adolescent an injury may impact growth — or growth might impact rehabilitation. And for a growing athlete that’s a huge difference in recovery and return to play as you were referencing. What is your best advice then, for a physician listening on when return to play is safe?
Dr. Mikutis: We are involved with our physical therapists as far as determining when the patient can return to sports. That’s after an operative or a non-operative injury. We closely collaborate with the physical therapists as to when the patient is optimally able to return to sports. That involves a number of physical evaluations and physical therapy that the patient should be able to complete. For instance, strength testing and comparing the injured leg to the uninjured leg. Their injured leg should be within 10 to 20% of the strength of the opposite side, and then should be able to do agility tests that are commensurate with their sports activity. In other words, we have the physical therapist run them through drills similar to what they’d be doing on, for instance, a soccer field. We physically know that they can complete these tasks even with the physical exhaustion and their knee holds out. I think the take-home message here is that we leave a lot to the physical therapists because they’re the experts in that field and are able to assess as to when the patient can return to sports.
Host: And transitioning away from sports for a minute, what about other causes of knee pain, such as referred pain from the hip or even tumor, infection, and even inflammatory arthritis. What would another physician need to know about those causes of knee pain?
Dr. Mikutis: Well, when we teach our residents and when we provide educational conferences, we always emphasize that whenever a pediatric patient, especially in the adolescent period, is complaining of knee pain it’s compulsory to examine the hip because hip pain can be referred down into the knee. One of the entities that we are looking for is a slipped capital femoral epiphysis that can masquerade as knee pathology. That is essential to do. Other things that we very commonly see are anterior knee pain or patellar-femoral pain that can be unrelated to trauma. It can be pretty debilitating and typically requires pretty exhaustive physical therapy to alleviate the discomfort or at least to allow the patient to get back to activities.
Other things that we think about if the patient has a big, swollen knee without any trauma you have to think about some type of inflammatory arthritis. Of course, if the patient presents acutely with a swollen knee and is sick you have to absolutely rule out a septic arthritis. Occasionally, we’ll see the patient who just presents to the office with a swollen either painless or mildly painful knee, and we have to think about other types of things like juvenile idiopathic arthritis. Another entity that we need to think about a lot more today — and it used to be kind of peculiar to the East Coast – is Lyme disease. I always entertain that diagnosis when I see a patient with a painless, swollen knee. That’s one of the rule outs in a swollen knee.
Host: Great information, Dr. Mikutis. And thank you for sharing that with us. We really appreciate your time today. For more information, visit ChildrensDayton.org, that’s ChildrensDayton.org. I’m Bill Klaproth. Thanks for listening.