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Melanie Cole (Host):  Welcome to UAB Med Cast. I’m Melanie Cole and I invite you to listen in as we discuss knee pain in adolescence. Joining me is Dr. Kevin Williams. He’s a Pediatric Orthopedic Surgeon and an Assistant Professor at UAB Medicine. Dr. Williams, it’s a pleasure to have you with us. This is such a great topic as knee pain is getting so pervasive in adolescence. Tell us a little bit about how prevalent it is and what are some of the most common reasons that you see adolescents for knee pain.

Kevin Williams, MD (Guest):  In terms of knee pain, I would say that about one in every five kids that presents to at least my clinic has a complaint of some type of knee pain. And those age ranges, span from about the age of six months to probably 18 years and as I focus on pediatrics, I’m sure as you continue on in life, that the knee pain is even prevalent in adults and elderly. But for today, we’ll focus on adolescence. And so, one of the most common causes of knee pain in adolescence is something that we talked about a little bit earlier, overuse injuries. And so as kids are continuing to grow up and to play one sport specifically and focus on competing within that sport year round; we are tending to see a little bit more overuse injuries of the knee which can be called traction apophysitis or also have different eponyms associated with them such as Osgood Schlatter’s, Sinding-Larsen-Johansson and various other causes of knee pain in the overuse ballpark.

Other common causes that we can talk about a little bit as well are idiopathic, related to growing pains. You can also have multiple issues in the knee as a result of trauma which include tearing of ligaments, menisci or breaking off osteochondral fractures as well. We can then also talk about infection, inflammation. You can have rheumatologic issues and then obviously, there’s knee aplasia and endocrine problems as well. And I would be remiss if I did not also speak on the fact that knee pain can also be referred from hip pain and lower back pain but hip pain specifically, in terms of looking out for a slipped capital femoral epiphysis as the knee pain is referred from the obturator nerve.

Host:  What a great point that you just made and as these growing youth athletes; their bones are growing and maybe it’s form and as you say, sport’s specialization, cross training. We are seeing a lot of sports specialization these days Dr. Williams and it certainly is becoming more of a problem. What sports in particular would you say predisposes children to some of that sports specialization knee problems or just knee problems in general. We hear a lot about ACL. Tell us a little bit about what sports you are seeing this most often in.

Dr. Williams:  As far as more ligamentous injuries, we see those pretty commonly in football and then particularly for the ACL, in soccer. Other sports such as basketball which include a little bit more jumping and a little bit more quick movements and pivoting, we see the anterior overuse injuries such as Osgood Schlatter’s and Sinding-Larsen-Johansson.

Host:  So, now tell us how you diagnose what the problem is. What interventions that you might try and some treatments. Speak about what you would do first as conservative measures for these growing athletes.

Dr. Williams:  To begin with, when you are evaluating knee pain in adolescents; your evaluation should be based on a thorough history and physical examination. Because there are so many causes of potential knee pain; you want to focus on the story and usually, as one of my mentors Evan Crawford up in Cincinnati, Ohio used to say; that the patient will tell you what’s wrong and will give you the diagnosis. So, that includes listening to the characteristics of the pain, associated symptoms, where the pain is, timing and making sure that you’re checking for things like mechanical symptoms and the actual length of time that the patient has had the pain because that can be indicative of certain types of injuries.

Being able to diagnose it is also based on doing a good physical examination and certainly one of the questions that the medical students and residents that follow me in clinic have are what are some of the best ways to be able to develop their musculoskeletal examination, particularly regarding the knee. And my answer for them is usually you just have to continue to repeat and get better as you do more and more. And so, on physical examination, some of the key aspects that you want to look at are to first gain the trust of the adolescent which is sometimes in clinic, the hardest part. But you want to examine both limbs and usually the limb that doesn’t hurt is the best limb to examine first. And then you want to pay particular attention to strength testing, range of motion testing and follow the inspection examination, percussion, the normal physical examination findings as you go about actually doing the examinations on these kids.

And so, you want to watch them walk. You want to look at their shoes to see if they have any type of foot or ankle issues that are causing them to wear out one side over the other. You also want to make sure that you’re examining their hip and their lower back especially in adolescents where a lot of alignment problems or even some types of rotational issues can contribute to the pain. For a lot of things, it’s a relatively simple diagnosis and you use your history, physical examination to develop what your treatment plan will be. And a lot of times, in terms of your treatment plan; if these are overuse injuries such as so commonly are then you want to concentrate on therapies to be able to actually get the patient back to sports, get them back to doing what they want to do and reducing their pain.

And so, that usually lies in terms of quadriceps strengthening because that’s one of the most important stabilizers of the knee and then hamstring stretching to keep yourself limber and being able to contribute to your full range of motion of your knee without pain. I would also like to mention a couple of different things that should probably indicate to you that you can examine the patient with additional imaging which include joint swelling in the form of an effusion of the knee, that usually indicates that something is bleeding into the knee. Whether or not that is the bone, cartilage, ligament, ligamentous disruption or meniscal tears; they can all be something that would be worth examining a little bit more with x-rays or even more invasive imaging such as MRI. And also, limb asymmetry is always a good reason for obtaining some type of x-rays or going through and evaluating the patient via imaging in addition to your history and physical examination.

Host:  What an excellent description of the assessment Dr. Williams. Just absolutely perfect. Now, how different are treatment modalities; I’m glad that you brought up quad and hamstring stretches and strengthening because for kids, these are so important for our adolescents and shoes, because we know that some of the shoes that they wear are going to be counterproductive to their growth and hip issues. All of these things are great points. How different are adults and adolescents when it comes to treatment? We hear about cortisone shots and viscosupplementation and all of these different modalities and how different is treating knee pain in adolescents?

Dr. Williams:  In my practice, I usually tend to stray away from performing any types of injections into the knee for pain. I think for the most part, those are reserved for times where you’re trying to prevent some of the signs and symptoms and the inflammation associated with arthritis. And so, in kids, you’re not usually having to deal with those inflammatory cascade intraarticularly that leads to the arthritis scenario. However, you are trying to decrease swelling usually, decrease pain and increase range of motion. So, in essence, they are very similar to adults in the fact that therapy and being able to have adequate stretching and strengthening exercise is paramount to contributing to the stability of the knee and also the pain profile of the patient. But we treat the kids with a little bit less of the intraarticular injections and try to trend towards joint preservation when at all possible.

Host:  What about medications? Do kids take anti-inflammatories for pain, depending on the diagnosis?

Dr. Williams:  Usually kids can take anti-inflammatories. My recommendations for the most part are that in specific situations where a kid has a overuse injury and we’re getting to a point where it’s bothering them enough to come in and see a doctor; then an over the counter anti-inflammatory can be helpful on an as needed basis. For more of the chronic overuse injuries and syndromes that can be associated with this; then scheduled anti-inflammatories for a short period can be relatively helpful and sometimes even providing a small steroid dose pack for someone who is incredibly inflamed and has been recalcitrant to certain measures such as physical therapy and symptomatic anti-inflammatories can be helpful in calming the inflammation process down.

Host:  Well I’m glad you brought up physical therapy because that was my next question. So, is that the typical course? Would be physical therapy and what do you think and for other providers and specifically even primary care providers that may be seeing knee pain in adolescents, ice, heat, bracing. When they are counseling their adolescents on dealing with this type of pain, speak about physical therapy and some of the modalities such as ice and bracing.

Dr. Williams:  I would give a glowing recommendation to all therapists out there because they do an amazing job, and we appreciate them so much. In terms of the role for physical therapy in adolescent musculoskeletal medicine; I think it’s absolutely paramount and they end up performing a lot of tasks where they are able to sit with the patient, go through exercises and especially concentrate like we were talking about on stretching and strengthening that we can’t necessarily do in clinic even though we want to because those are actually the treatments for a lot of these problems that present with adolescent knee pain.

And so, I think their role is optimal in terms of being able to integrate well with the providers both from an inpatient and outpatient basis and then as far as their modalities, I think from the literature perspective, that there are a lot of proven treatments to be able to treat some of these particular items and issues with adolescent knee, however, what I usually tell patients in terms of external modalities whether it be ice, heat, stim, ionophoresis, cupping, dry needling, things like that; I usually tell them if it’s working, then continue doing it. If it’s not working, you don’t necessarily have to keep doing it but any of those particular items can be helpful in getting the patient back to where they want to be in terms of their strength and range of motion.

Host:  That’s excellent advice and before we wrap up, behavior and lifestyle. We’re certainly seeing an obesity epidemic among our youth and of course this is going to contribute down the line to arthritic conditions as you discussed a little bit before. What would you like to say as final thoughts for other providers about knee pain? This is such a big broad topic Dr. Williams. What would you like other providers to know about working with their adolescents and looking at some of those lifestyles or gait or shoes or weight or any of these things that we’ve been discussing here today and when do you feel it’s important that they refer to the specialists at UAB Medicine?

Dr. Williams:  In terms of lifestyle modifications, I think a healthy balanced diet is absolutely critical to the development of kids especially when you’re going through conditions that are maintaining a decent amount of bony growth and especially during overuse injuries where your body is constantly trying to heal yourself and so I think one of the most important aspects of nutrition is making sure that you are getting enough vitamin D and calcium for your musculoskeletal health along with everything else that comes with a balanced diet.

Especially these days, it’s somewhat difficult to even discuss patient’s weight with families as we live in a culture where you don’t want to necessarily tell other people how to live their life and you don’t want to be over paternalistic. But there’s certainly a role for that in clinic if you are noticing some conditions that are associated with like you were talking about, overweight or obese children. And I think there’s definitely a role for the provider in discussing that with the family and making sure that they’re aware without being overly pushy about your suggestions. And I think that’s really difficult and that’s something that each provider has to be able to navigate in their clinics and be able to figure out how to have those discussions.

And then in terms of being able to figure out which knee pain to refer. Usually we talk about if the pain is lasting for quite some time, if it lasts longer than two weeks and is getting worse and not getting better, if it’s affecting the performance of the child in whatever capacity they’re trying to actually either compete or just going about their daily life, if it’s causing limping significantly for an extended time period, if it’s all the child thinks about especially when they are playing a sport or when they are doing a certain activity that causes the pain, if there’s a trauma associated with it, specifically contact or noncontact injuries, if they have mechanical symptoms or which include clicking, popping, catching, feeling like the knee is giving out or an effusion, swelling about the knee, focally or diffusely or obviously, any constitutional symptoms which would indicate any type of infection such as a fever, chills, night sweats, lack of diet, things like that are things to think about when you’re considering if you want to refer your child with knee pain to another provider here at UAB.

Host:  Thank you so much Dr. Williams. What an excellent episode. That was so informative for other providers. Thank you again for joining us and a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patients or more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole.