1. What more should you know about Brenda?

Inquire about the onset, duration, and nature of her limp and pain, as well as recent weight gain or alteration in activity. Clarify whether pain is increased by movement or by rest and if it is referred. I should also inquire about systemic symptoms such as fever, fatigue, or weight loss, which could indicate infection or malignancy. Explore the menstrual history and endocrine or orthopedic family history. Ask about psychosocial problems like activity level, lifestyle, and school attendance. Having this information further narrows down the differential diagnoses, like slipped capital femoral epiphysis (SCFE), which is seen frequently in obese adolescents.

2. What specific exam techniques should you perform and why?

Begin with inspection for asymmetry, swelling, or deformity of the hip and leg. Observe her gait for an antalgic or Trendelenburg pattern. Palpate the hip, groin, and knee to locate tenderness. Perform range of motion (ROM) tests, especially internal rotation of the hip, which is limited and painful in SCFE. Conduct the Thomas test to assess hip flexor contracture and the log roll test for intra-articular hip pathology. Assess leg length and muscle strength. A thorough neurovascular exam is essential to rule out other causes. These targeted maneuvers help differentiate SCFE from other causes of musculoskeletal or referred pain.

3. What diagnostic tests should you order and why?

Order bilateral anteroposterior (AP) and frog-leg lateral X-rays of the hips and pelvis to assess for slipped capital femoral epiphysis (SCFE), as SCFE is frequently bilateral. X-rays are helpful in seeing the displacement of the epiphysis, which can be subtle in the initial stage of the disease (Johns & Tavarez, 2023). If X-rays are equivocal but have high suspicion, utilize MRI for early detection. Infection may be suspected on basic labs like CBC, ESR, and CRP if infection is suspected (e.g., septic arthritis or osteomyelitis). Imaging is very important in the early diagnosis of SCFE to avoid progression, avascular necrosis, and long-term effects like osteoarthritis or hip deformity.

Kathy

Case Scenario 3: Robert

Case Scenario 3: Robert is a 14-year-old undergoing a rapid growth spurt who complains of a tender mass over the anterior tubercle of one knee. He says the pain improves with rest and worsens with activities like squatting, kneeling, jumping, and climbing stairs.

What does the evidence suggest about the etiology of his condition?

How should you manage this condition?

What type of anticipatory guidance should you share with Robert and his parents?

Robert is a 14-year-old adolescent with a tender mass over the anterior tubercle of one knee that worsens with activities (like squatting, kneeling, jumping, and climbing stairs) and improves with rest. Based on Robert’s presentation in this case scenario, he most likely is experiencing Osgood-Schlatter disease (also known as osteochondritis of the tibial tubercle) is a traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon.

Etiology

Osgood-Schlatter disease is an overuse injury commonly seen in physically active adolescents. It occurs secondary to repetitive strain and microtrauma from the force applied by the strong patellar tendon at its insertion into the relatively soft apophysis of the tibial tubercle. This stress leads to inflammation and in more severe cases, can cause a partial avulsion of the apophysis. The mechanical strain is heightened during periods of rapid growth and with increased physical activity. Although rare, a direct trauma may result in a complete avulsion fracture. Contributing risk factors include tightness in the quadriceps or hamstring muscles and misalignment of the extensor mechanism (Smith & Varacallo, 2023). Osgood-Schlatter clinically presents with pain and localized swelling over the tibial tubercle. Pain is typically reproduced by resisted knee extension or squatting. The condition is self-limiting and usually resolves once skeletal maturity is reached and the growth plate closes (Kienstra & Macias, 2024).

Risk factors:

· Male gender

· Ages: male 12-15, girls 8-12

· Sudden skeletal growth

· Repetitive activities like jumping and sprinting (Smith & Varacallo, 2023).

Clinical Presentation: The most common presenting complaint is anterior knee pain that increases gradually over time, from a low-grade ache to pain that causes a limp and/or impairs activity. Pain is exacerbated by direct trauma, kneeling, running, jumping, squatting, climbing stairs, or walking uphill, and is relieved by rest. Involvement usually is asymmetric, although both knees are involved in 25 to 50 percent of cases (Kienstra & Macias, 2024).

Diagnosis is based on history and examination. Radiographs are not necessary unless the patient has atypical complaints (pain at night, pain that is unrelated to activity, acute onset of pain, associated systemic complaints) or pain that is not directly over the tibial tubercle. Upon physical examination, tenderness and soft tissue or bony prominence of the tibial tubercle can be noted. Pain may be reproduced by extending the knee against resistance, stressing the quadriceps, or squatting with the knee in full flexion. Straight-leg raising usually is painless. Pain that is more prominent in the patellar tendon than the bony prominence, is suggestive of patellar tendinopathy (jumper’s knee). The hamstrings may be shortened and the quadriceps taut. Quadriceps flexibility is assessed by passively flexing the knee with the patient prone (ie, the Ely test). The range of motion of the knee is not affected, and the knee and patellofemoral joints are stable. The remainder of the knee examination is usually normal. The range of motion of the hip should also be evaluated to make sure that the knee pain is not related to referred pain from pathology in the hip (eg, due to slipped capital femoral epiphysis, Legg-Calvé-Perthes disease). Most patients can be diagnosed and managed without a point-of-care ultrasound. However, the US can potentially aid in diagnosis in more complicated cases. If needed, plain lateral radiographs are appropriate to help exclude other conditions (e.g., tibial apophyseal fracture, tumors, or osteomyelitis) in patients who have atypical features (Kienstra & Macias, 2024).

Erythema and warmth of the tibial tubercle, which suggest an acute inflammatory process, require additional evaluation (eg, for osteomyelitis). However, these findings must be interpreted with caution in patients who have used an ace wrap or heating pad before presenting for evaluation. MRI has been proposed as a means of classifying the staging of Osgood-Schlatter disease, which may help with prognosis, but it is usually not indicated (Kienstra & Macias, 2024).

Management

The condition is self-limiting but may persist for up to 2 years until the apophysis fuses. The management of Osgood-Schlatter disease has not been studied in randomized controlled trials. Observational studies suggest that most patients respond to nonsurgical treatment and that those with persistent symptoms may benefit from surgical therapy (eg, ossicle excision). Osgood-Schlatter disease is managed conservatively, focusing on pain relief and activity modification (Kienstra & Macias, 2024):

1. Pain Management

Non-pharmacological Treatment:

· Applying ice packs (for 20–30 minutes at a time at least twice per day) after physical activity to reduce swelling.

· Wearing a tibial tubercle pad or patellar strap during activity to relieve tension on the tibial tubercle (Kienstra & Macias, 2024).

Pharmacological Treatment:

· Using NSAIDs (e.g., ibuprofen) or acetaminophen for short-term pain control (3–4 days as needed).

· Patients with persistent pain that alters their ability to participate in sports for more than three months may benefit from an injection of hyperosmolar dextrose (e.g., 12.5 percent dextrose) by a sports medicine specialist or orthopedic surgeon.

· Glucocorticoid injections generally are not recommended because of complications, primarily related to subcutaneous atrophy (Kienstra & Macias, 2024).

2. Rest and Activity Modification

· Rest from painful activities (that exacerbate the pain such as squatting, kneeling, jumping, and climbing stairs) but complete avoidance of sports is not necessary.

· Robert can continue sports if the pain is mild and resolves within 24 hours.

· Avoid kneeling, squatting, or positions that aggravate symptoms.

· Crutches are rarely indicated, and knee immobilizers are contraindicated. Extended periods of casting worsen the ultimate outcome because they lead to atrophy of the quadriceps and hamstring muscles (Kienstra & Macias, 2024).

3. Physical Therapy

· Begin quadriceps and hamstring stretching and strengthening exercises once the pain is adequately controlled.

· PT helps relieve tension at the tibial tubercle and prevents recurrence (Kienstra & Macias, 2024).

4. Advanced Therapy (for refractory cases)

· In persistent pain (>3 months) despite conservative care, hyperosmolar dextrose injection (12.5% with lidocaine) has shown benefit.

· Corticosteroid injections are avoided due to risk of skin and soft tissue atrophy.

· Surgery (e.g., ossicle excision) is rarely needed and only considered after growth plate closure (Kienstra & Macias, 2024).

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