Chapter 11 Pain in adolescence
Case 11.1
1. What is your differential diagnosis? Justify your choices.
| Differential diagnosis | Justification |
|---|---|
| Miserable Malalignment syndrome (MMS) | Commonly presents with excessive femoral anteversion, squinting patella, patella alta, and an increased Q-angle with excessive external tibial rotation |
| Osgood-Schlatter disease | Presents with anterior and superficial tibial tuberosity knee pain, and is described as an overuse injury in teens, especially during growth spurts. Pain increases with exercise and decreases with rest. Pain commonly worsens over 2 years of sustained activity levels |
| Sinding-Larson-Johansson disease | Presents with anterior infra-patella knee pain, and is described as an overuse injury in teens, especially during growth spurts. Pain increases with exercise and decreases with rest. Pain commonly worsens over 2 years of sustained activity levels |
| Multipartite patella | Presents with general anterior knee pain, most commonly at the supralateral pole. Bilaterality is uncommon. There is a strong male predominance and the aetiology is unknown |
| Pathologic medial plica | There is pain over the medial femoral condyle. Repeated trauma or irritation may lead to inflammation and fibrosis of the plica. A diagnosis of symptomatic plica is made by exclusion, and the presence of a plica by itself does not indicate pathology. Symptoms commonly mimic those of a torn meniscus |
| Chondromalacia patellae | Patients usually report anterior knee pain in flexion when weight-bearing (eg: when climbing stairs). Contributing factors include weakness and tightness of quadriceps muscle, genu valgum, increased Q angle and patella alta |
Case 11.2
1. Describe:
b McMurray’s test.
2. What is the most likely diagnosis? What leads you to this conclusion?
Anterior cruciate ligament tear:
3. What further testing would you perform to confirm your diagnosis?
Physical examination of anterior cruciate ligament tears:[1]
4. What is the function of:
5. What is the investigation of choice for confirmation of an anterior cruciate ligament or posterior cruciate ligament tears?
Magnetic resonance imaging (MRI) is the most sensitive and specific for diagnosing complete anterior cruciate ligament rupture. Primary and secondary MRI signs for complete anterior cruciate ligament are well established in the radiologic literature.[2]
Case 11.3
1. What is your differential diagnosis? Describe a common presentation of each. What is the most likely diagnosis?
| Differential diagnosis | Common presentations |
|---|---|
| Right AC dislocation (Grade I–IV of Rockwood classification) | This typically presents with a sudden onset of localised pain at the acromioclavicular joint, usually resulting from trauma. Pain increases with any upper limb motion/activities. Tears of the acromioclavicular and coracoclavicular ligaments (from a fall onto the tip of the shoulder) allow the upper limb to drop away from the clavicle, producing separation of the acromioclavicular joint |
| Right rotator cuff tear (especially supraspinatus) | Patients with a rotator cuff tear will often experience a sudden pain or tearing sensation in the shoulder during activity. In minor rotator cuff tears, patients may be able to continue sport or activity only to have an increase in pain upon resting later (particularly that night or the following morning). In complete rupture of the rotator cuff, the pain may be disabling, preventing the patient from performing further activity. Patients with a rotator cuff tear usually experience pain that is localised to the shoulder. Occasionally, pain may radiate into the upper arm, shoulder blade, upper back or neck. The pain associated with a rotator cuff tear is usually experienced as an ache that increases to a sharper pain with activity |
| Right clavicle fracture | Patients will commonly experience a sudden onset of sharp, intense pain at the time of injury (fall onto out stretched hand). Pain is usually located along the clavicle. Pain may increase when attempting to perform movements of the upper limb such as arm elevation, overhead activities, taking the arm across the chest or heavy pushing, pulling or lifting activities. There may be a step defect present |
| Right fractured acromion | Pain is sudden and severe, and typically presents on the tip of the acromion and is increased with all upper limb movements. Injury usually results due to a fall onto the lateral aspect of the shoulder |
| Short head of biceps tendon avulsion | Sudden and severe loss of powerful flexion typically results from attempting to lift excessive loads. A ‘Popeye’ deformity maybe present. Pain is localised over the coracoid process and aggravated with flexion against resistance |
| Right subacromial bursitis | Presents with pain and weakness when the arm is abducted through a 60 degree arc. There is increased pain on palpation of the anterior glenohumeral joint. If acute, then the bursa will be hot and tender. If chronic, there is less inflammation and movement is less restricted |
| Brachial plexus lesion: right ‘burner/stinger’ (transient brachial plexus irritation), right Erb’s Palsy, right Klumpke’s Palsy | Pain is burning and radiating from the affected shoulder circumferentially down the arm along the dermatome affected. Injury is usually due to a stretching of the brachial plexus, resulting in traction of the nerve roots. It is important to note that no complaints of neck pain occur with ‘stingers’. There is often weakness of shoulder abductors and external rotators as well as biceps weakness |
The most likely diagnosis in this patient is an acromioclavicular dislocation.
2. What further testing would you perform to confirm your diagnosis?
Further testing should include:
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