Questions & answers

Questions & answers

Joni Jacobsen 1. !Nuzt f&her elicit? histoy Bosch, PhD, do you want to Does Jennifer recall the onset of pain, and if so, was it abrupt or insi...

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Joni

Jacobsen

1. !Nuzt f&her elicit?

histoy

Bosch,

PhD,

do you want to

Does Jennifer recall the onset of pain, and if so, was it abrupt or insidious? Can she recall any trauma prior to the onset of the pain? Can she point to where it hurts? What activities make the pain better or worse? At what level does she rate the pain? Is the pain equal in both knees? Does she ever notice that her knees catch, give way, or lock up? Has she noticed redness, warmth, or swelling? Has she heard any “pop“? Does she describe any sensation of “sliding” or “twisting”? Has she ever had a frank knee dislocation? Jennifer cannot recall the onset of her knee pain. She denies having experienced any trauma to the knee. The pain includes the entire kneecap “behind her knee.” When asked to point to where it hurts, Jennifer covers her entire knee (the “grab” sign). She describes the pain as most severe when she walks up stairs or rides her bike. Running also hurts, and squatting causes severe pain. She has also noticed that her knees hurt when she has been sitting in class, a theater, or a car for a long time (theater sign). The pain varies in intensity from 3 to 7 on a lo-point scale. The pain is similar in both legs. She has never had her knees catch, pop, give way, or lock up. She has never seen any redness, but she has noticed occasional mild swelling along the upper lateral edge of her knee. She has never had a knee dislocation and reports no sliding sensations.

2. What additional will you make?

1999

(Data on page 144.)

tremity, patellar tracking, focal tenderness, and the presence of any swelling or effusion should be assessed. Jennifer’s walking gait is normal. She is able to do a deep knee bend but complains that doing this makes her knees hurt, especially when she gets approximately half way down. When Jennifer stands with her feet together, you note “squinting,” or m-facing of the patellae. She has mild pronation of both feet. Jennifer does not have patella alta, because the anterior surfaces of her patellae point forward rather than toward the ceiling when she sits with her lower legs dangling over the edge of the examination table. You note mild crepitus bilaterally with both passive and active flexion and extension. To test patellar tracking, you have Jennifer sit on the examination table with her legs flexed, place your hand on her knee so that the medial and lateral borders can be palpated with your finger and thumb, and ask her to extend her leg. No lateral tilting is noted until the minor lateral tilt that marks the normal patellar movement is in full extension, indicating that Jennifer’s patellar tracking is within normal limits. You perform a lateral compression test by having Jennifer rest her thigh on a support to maintain her knee flexion at about 25 degrees. With your thumbs, you gently displace the patella medially, which elicits pain. Jennifer has no pain when the patella is displaced laterally While flexing Jennifer’s legs through passive range of motion, a tender area is noted on the medial aspect of the knee near the femoral condyle. Jen-

nifer has no reports of pain with range of motion to the hips. No effusions, redness, or warmth are noted. The Q angle (the angle caused by drawing imaginary lines connecting the center of the patella and the anterosuperior iliac spine and the center of the patella and the center of the tibia1 tubercle) appears to be about 20 degrees. 3. What is the most likely diagnosis? Osgood-S&latter disease is unlikely because no swelling is found in the area of the tibia1 tubercle. Patellofemoral arthritis tends to involve pain at the lateral patellofemoral joint line rather than the medial line, as seen with Jennifer. The patient is not overweight, has no limp, and is able to localize the pain to the kneecap; in addition, the pain is not reproducible with range of motion to the hip, which tends to rule out referred pain from a slipped capital epiphysis. Jennifer does not describe activities that could have caused trauma or overuse syndrome. Your examination has already ruled out abnormalities in tracking or patella alta. Because tenderness is located on the medial aspects of Jennifer’s patellae rather than the superolateral quadrants or inferior poles, it is not likely that she has bipartite patellae. Indeed, Jennifer has offered a classic description of chondmmalacia patellae, also known as idiopathic anterior knee pain, patellofemoral pain, or patellofemoral malalignment syndrome. The term chondromalacia patellae has lost favor, because cartilage changes are rarely detectable.

physical assessments

Assessm.ents should be made while the patient walks, stands, sits, is supine, and is prone. Gait, range of motion, alignment of the knee and the lower ex-

May/June

ARNP

Joni Jacobsen Bosch is a Pediatric Nurse Practitioner Iowa Hospitals and Clinics, Iowa City. J Pediatr Health Care. (1999). Copyright

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CLINICAL INSIGHTS

Jacobsen Bosch

Patellofemoral pain is a diagnosis of exclusion and may be related to malalignment or maltracking, as well as poorly developed quadriceps (Busch, 1996). It may also be related to the adolescent growth spurt and strenuous athletic activities (Gruber, 1979). The pain is thought to be a result of the increased pressure from the malaligned patella bearing down on the underlying joint as it traverses the joint during flexion and extension, with the worst pressures exerted in full flexion, especially when an imbalance exists between the pressures exerted on the joint by the stabilizing soft tissues (Busch, 1996; Stanitsky

1994). The most common complaints are pain behind the entire patella (when asked to show where it hurts, the patient grabs the entire kneecap, hence the “grab sign”), worsening of pain with activities involving flexion, such as climbing stairs, bicycle riding, and deep knee bends, and discomfort following prolonged sitting (theater sign). As previously described, squinting patellae may be noted, tracking may or

may not be normal, and erythema or effusion are uncommon. Medial displacement (patellar compression test) causes marked pain (Agiletti, Buzzi, & Insall, 1993). With a good history and physical examination, imaging is rarely needed. Computed tomagraphy may be used to evaluate the joint in flexion. Radiograms of the anteroposterior, lateral, and tangential views of the joint may help rule out other causes. Merchant’s technique with the knees partially flexed may provide the most sensitive plain film (Busch, 1996). However, imaging should not be necessary with a classic presentation. 4. What treatment will you prescribe? Most patients may be reassured that they do not have a serious problem. Symptomatic pain relief with nonsteroidal anti-inflammatory drugs or use of knee sleeves, ice massage, or heat are all appropriate. A therapist may be. able to demonstrate the McConnell taping technique to the patient to improve

patellar tracking. Activities that cause pain, such as squatting and bicycle riding, should be avoided. Reconditioning is important. Straight leg raises to 100 repetitions per day with weight gradually increased to 10 pounds can help strengthen the quadriceps. If flexion is used, it should not exceed 20 degrees, or the pain may be worsened. If a weight machine is used, the knee should be placed into extension before the weight is added (Busch, 1996). Surgery is rarely indicated and may worsen the overall outcome.

REFERENCES Busch, M. (1996). Sports medicine. In R. Morrissy & S. Weinstein (Eds.), Pediatric Orthopedics (pp. 1181-1228). Philadelphia: Lippincott-Raven. Gruber, M. (1979). The conservative treatment of chondromalacia patellae. Orthopedic Clinics of

North America, X3,105-115. Stanitsky, C. (1994). Anterior knee pain syndromes in the adolescent. Instructional Course Lectures, 43,211.226. Agiletti, I’., Buzzi, R., & Insall, J. (1993). Disorders of the patellofemoral joint. In J. Insall, R Windsor, M. Kelly, W. Scott, &I’. Aglietii (Eds.), Surgery of the Knee, (2nd ed., pp. 241-385). New York: Churchill Livingston.

WANTED: CHILDREN’S DRAWINGS The Journal is interested in publishing children’s drawings of their responses to illness, treatment, or encounters with the health care system or personnel. Please send the drawings, along with the child’s age, gender, any pertinent information regarding the child’s condition, and written parental permission to print the drawing, to Bobbie Crew Nelms, PhD, RN, CPNP 3133 Barbara St San Pedro, CA 90731

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JOURNAL OF PEDIATRIC HEALTH CARE