Joint pain and swelling in adolescence

Chapter 10 Joint pain and swelling in adolescence



Case 10.1



History


James is a 12-year-old boy who has recently begun high school. His mother has bought him to you because she is worried about his recent onset of bilateral knee pain, which she believes is related to playing soccer, and she thinks you may be able to help.


James describes a gradual onset over the last month of localised pain and tenderness over the anterior aspect of both knees below the patella. The pain is a vague ache that worsens with activities, such as running, kicking, squatting and jumping. James finds it difficult to walk up and down stairs due to the pain. The pain improves with rest or modification of the aggravating activities. The pain came on for no apparent reason, and there was no traumatic incident reported. There is moderate swelling over the site of pain on both knees, and the area is tender to touch. The severity of pain has not worsened since the onset. There is no clicking, locking or giving way in either knee. There is no weakness or motor sensory phenomenon. The pain does not radiate.


James feels the pain particularly when he attends training sessions for soccer, and during the weekly game, and is concerned because he has had to miss training this week due to pain. He complains about the ugly ‘lumps’ that have developed at the top of his shins.


James is an otherwise healthy adolescent with nothing of note in his past medical history. He has never been hospitalised, nor suffered any accidents. He has sprained both ankles at various times during sport, but these injuries have been mild with full resolution. All other systems are unremarkable.



Questions



1. Using only this information, list the possible causes of James’ presenting symptom(s). Justify your answer.

2. Why was James asked about:
a the quality of the pain

b the site of the pain

c the significance of swelling

d the significance of clicking, locking or giving way

e the significance of activities that aggravate the pain?

3. What do you need to examine in this patient?


Physical examination

























































General James is a tall, healthy looking 12-year-old boy of normal weight. He does not appear to be in excessive pain
Vitals •Pulse rate/min 74
  •Respiratory rate/min 18
  •Blood pressure mm Hg 115/75
  •Height (cm) 156
  •Weight (kg) 46
  •Temperature (degrees C) 37
knee examination Gait Normal
Inspection Proximal tibial swelling with mild enlargement of the tibial tuberosity bilaterally and symmetrically
Palpation Point tenderness over the tibial tuberosity, with localised swelling bilaterally. Bilateral hamstring hypertonia. No joint line tenderness; no patellar tendon tenderness
Swelling tests Negative for effusion
Orthopaedic tests Negative for ligamentous instability or meniscal signs. Negative for patellar tracking signs. Positive resisted knee extension for pain provocation
Knee range of motion (ROM) Normal with full range of motion all planes
Neurovascular exam of lower extremity Unremarkable
Evaluation of hip, ankle and lumbar spine Normal


Questions



4. What information can you obtain from these findings? Can you narrow your differential diagnosis?

5. Explain the significance of the following signs, in context of your differential diagnosis:
a blood pressure, respiration, pulse and temperature

b enlargement of the tibial tuberosity bilaterally

c tenderness of the tibial tuberosity

d pain with resisted knee extension.

6. What investigations are required? Why? What would you expect, based on the physical examination findings?


Investigations


Knee radiograph lateral projection left and right. Figure 10.1 shows James’s right knee.


image

Figure 10.1


(Source: Taylor J, Hughes T, Resnick D. Skeletal Imaging Atlas of the Spine and Extremities. Missouri: Saunders; 2010:572, Fig 9-22 A)



Questions



7. What is your final diagnosis, based on these results? Justify your answer.

8. Explain the significance of the X-ray appearance in context of your differential diagnosis.

9. Are any further investigations required?

10. What is the functional anatomy of ossification of the tibial tuberosity?

11. What is the aetiology and pathophysiology of this disorder?

12. Describe the natural history of the disease.


Case 10.2



History


Brigit is a 14-year-old ballet dancer who presents to you with right-sided ankle and foot pain. She describes it as an ache and it started when she commenced ‘èn pointe’ this year. Although she has been dancing for 10 years and her teacher believes she is ready for this progression, no amount of stretching both before and after a class alleviates the problem. The pain is described as ‘7 out of 10’ on the Visual Analogue Scale (VAS), and is worse in the morning. She has recently noticed some swelling and redness around the ankle as well. When describing the pain, she points to three sites: the medial aspect of the big toe; the plantar aspect of the ankle; and the posterolateral aspect of the ankle. She is otherwise in good health and has had no injuries of either ankle or foot. She states that her ballet teacher believes that she is somewhat ‘flat-footed’, compared to other girls in the class. Her mother has noticed she has recently had a growth spurt but her weight remains the same. Brigit admits to not drinking enough water.



Questions



1. Using only this information, list the possible causes of Brigit’s presenting symptom(s). Justify your answer.

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Joint pain and swelling in adolescence

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