Pediatric Knee Pain: Expert Guidance for Parents in Singapore

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Knee pain is common in children. It may be due to injuries, growing pains, or a more persistent pain known as Osgood-Schlatter’s Disease. Injuries are common in children who participate in sports. Your child’s healthcare provider is usually quite good at diagnosing injuries, but sometimes an MRI or x-rays are needed. Growing pains are a common cause of knee pain in healthy children. These are a harmless condition and seem to come and go without any reason. Osgood-Schlatter’s Disease is a condition often seen in teenagers and is due to inflammation of the area just below the knee, causing pain and swelling. Osgood-Schlatter’s pain consistently comes back after exercise and is relieved by rest, but activity often makes the pain worse. This is a diagnosis we often see a pediatric orthopedist for. These physicians have special training in treating children and are well-suited to help diagnose reasons for knee pain and recommend the appropriate treatments. This article will discuss some of the more common reasons for knee pain and help guide parents on when to seek a referral to see a pediatric orthopedist. This article will focus on when not to worry about simple knee pain, as there are too many diagnoses to cover in a single article, and most of them are of no long-term concern.

Understanding Pediatric Knee Pain

The largest study of knee pain etiology in adolescents found that traumatic knee injuries were responsible for a third of all knee pain cases. The majority of traumatic knee pain is due to ligament or meniscal injuries and juvenile osteochondritis dissecans (OCD), mainly occurring in the setting of high-risk sports. The effect of malalignment on knee pain is difficult to determine, but a longitudinal study has shown that patellofemoral pain, which is highly prevalent in adolescents, is significantly associated with an increase in patellar malalignment. Other structural factors which may play a role in the development of knee pain include muscle weakness, asynchrony of growth, and musculoskeletal pain amplification. Complex Regional Pain Syndrome (CRPS) has also been diagnosed as an etiology of knee pain. An existing mood disorder has been shown to increase the risk of knee pain persistence and chronification. In summary, knee pain in the non-traumatology setting is likely to be due to an interaction of several biopsychosocial factors, but more research is needed in order to fully understand these pathways.

Associations of specific patient characteristics with knee pain have not been entirely consistent across numerous studies, which potentially reflects the heterogeneity of pain etiologies in the pediatric populations. Knee pain intensity has most consistently been associated with activity or functional limitations. Pain frequency has been associated with longer pain duration. However, other characteristics of pain such as its chronicity and pain type have not been consistently linked to activity limitations. Since it is likely that knee pain in adolescents is related to sports and other recreational activities, it is possible that the effect of pain on function may only become evident once adolescents commence the specific activities that exacerbate or incite the pain. This notion is supported by the weak association of knee pain with activity limitations in a cross-sectional study of adolescent tennis players. This demonstrates that the interactions between acute or overuse knee injuries and pain in the complex adolescent musculoskeletal system, and their influences on physical activity and function, are still not fully understood.

Importance of Seeking Expert Guidance

An acute knee injury can cause severe pain and be disabling. Treatment and prognosis may be more complex if the injury involves a growth plate. This is because an injury to a growth plate can disturb normal growth and cause a limb to become crooked or of unequal length. Your knee pain specialist┬áhas ways to tell if the injury involved a growth plate and may need to x-ray the injured area again in six months to make sure that it sustained no damage. Any knee injury that results in any of the following symptoms should be seen by a doctor as soon as possible: – A pop or snap at the time of injury – An inability to move the knee – Persistent swelling – Pain that does not improve with rest and ice Relatively minor injuries can develop into long-term problems. The following symptoms are signs that there may be something more serious than a minor injury and worthy of a doctor’s evaluation: – Pain and swelling that are out of proportion to the injury – Locking or instability of the knee – Inability to put weight on the joint without pain

Common Causes of Pediatric Knee Pain

There are three basic etiologies for pediatric knee pain across all age groups. These include overuse injuries, traumatic injuries, and growth-related conditions. Overuse injuries can occur in growing, active children usually during a growth spurt. The quadriceps muscle is so strong that it can put excessive force on the still-growing patella at its insertion point on the tibia. If the repetitive stress is greater than the ability for the bone to repair itself, an apophysitis can occur. This is an inflammation where the patellar tendon inserts on the patella. This condition is known as Osgood Schlatter’s disease and typically occurs in adolescents 10-15 years of age. Sinding Larsen Johansson syndrome is a similar condition in younger children where there is inflammation at the other end of the patella where the patellar tendon inserts on the tibia. This typically occurs in children between the ages of 7-12. Finally, stress injuries to the bone can occur in the adult portion of the tibial bone just below the knee joint known as the tibial tubercle. This condition usually occurs in children ages 8-14 in both sexes, but it only causes knee pain in girls. Excessive force to this bone can actually cause it to break, and the resulting stress injury is known as a tibial tubercle avulsion. This condition can cause pain and limping, and if not treated properly, it can cause altered mechanics and chronic knee pain.

Overuse Injuries

Treatment of these conditions involves relative rest from aggravating activities, ice, physiotherapy, and a guided return to sport once pain has settled and strength and flexibility have returned to normal.

The most common overuse injuries in the knee are patellar tendonitis (also known as Osgood Schlatter’s), which affects the area just below the kneecap, and pain at the front of the knee around the kneecap, which can be due to a number of different diagnoses. The pain may be related to activity or can be present with daily activities and at rest. In most cases, the pain will gradually increase over a period of weeks and can persist for a number of months if not assessed and treated properly. Any activity that increases stress on the knees can lead to overuse injuries coming on or getting worse.

Overuse injuries are the most common cause of knee pain in the younger sporting population. They can occur in children who start an intense new sport or activity, or in those who increase the amount, duration or intensity of their training. They are more common in children who do a lot of jumping and running activities. During growth spurts, the bones may sometimes grow faster than the muscles, causing them to become tight or weak. An imbalance in strength and flexibility around the knee can also lead to overuse injuries.

Traumatic Injuries

A sprain to the ACL is a relatively common sports injury in older children and adolescents. This injury can cause immediate swelling and pain, with an unstable feeling in the knee joint. This may require assessment by a specialist and can occasionally require surgical intervention, particularly if there is associated damage to the cartilage. An injury to the cartilage can cause locking or giving way of the knee and may require keyhole surgery to remove the damaged cartilage.

High-energy injuries to the knee also have the potential to cause ligament or cartilage injuries. The knee joint is surrounded by a capsule and supported by ligaments, both of which provide stability to the joint. If a significant force is applied to the joint, this can cause a stretching or tear of the ligaments and/or damage to the cartilage. An example of this is an injury sustained during a football tackle.

A direct blow to the knee can cause a deep bruise to the bone called a bone contusion. This can be painful and cause limping for several weeks. Fortunately, most bone contusions seen in the pediatric population will resolve with no long-term effects. Any cut to the knee has the potential to become infected, particularly if it is a dirty or deep wound, and should be reviewed by a doctor.

Injuries that are caused by significant forces, such as a fall from a bike or a direct blow to the knee, are usually traumatic. The most serious traumatic injury is a fracture. This can occur in a child who sustains a high-energy injury, such as a fall from a significant height or a motor vehicle accident. If a child has significant swelling and an inability to bear weight after an injury, this may indicate a fracture and they should be reviewed by a health professional. If a fracture is not detected on initial X-rays, it may be seen on repeat X-rays a week or two later. The child should be reviewed regularly if there is suspicion of a fracture.

Growth-related Conditions

Juvenile arthritis is an umbrella term for all types of arthritis developed in a patient aged less than 17. It is an autoimmune, inflammatory condition. Specific symptoms of knee pain and stiffness worse in the morning and improving with activity may often be mistaken for other causes of knee pain. A variety of tests are available ranging from simple blood tests to examination of synovial fluid from the joint to confirm the diagnosis. Treatments include medication, patient and family education, physiotherapy and exercise, and in severe cases, joint replacement.

The purely clinical diagnosis of Osgood-Schlatter disease is based on the history and physical examination showing local tenderness and swelling at the tibial tuberosity. X-rays can be taken to rule out other pathology but are not usually required in straightforward cases. Imaging is rarely required. Osgood-Schlatter disease can be distinguished from other more severe causes of knee pain like tumors, staphylococcal or tuberculous osteomyelitis, and Osgood-Schlatter disease (osteochondritis dissecans).

Sinding-Larsen-Johansson disease presents similar symptoms but is localized at the lower pole of the patella. Both conditions are treated conservatively. This includes a reduction in activity to a pain-free level, stretching and strengthening exercises, ice, and anti-inflammatory medication (if necessary). Symptoms may persist from a few months up to a few years, but usually resolve completely with closure of the growth plate. Surgery is rarely required.

Osgood-Schlatter and Sinding-Larsen-Johansson diseases are overuse injuries thought to be caused by repeated stress on the proximal patellar tendon at the tibial apophysis and the distal end of the patella, respectively. Osgood-Schlatter disease is most common in boys aged 10-15. Symptoms include pain and swelling just below the knee which is often made worse by exercise and eased by rest. In severe cases, a lump can form at the site of pain due to a calcified deposit on the tibial tuberosity. Sinding-Larsen-Johansson disease presents similar symptoms but is localized at the lower pole of the patella. Both conditions are treated conservatively. This includes a reduction in activity to a pain-free level, stretching and strengthening exercises, ice, and anti-inflammatory medication (if necessary). Symptoms may persist from a few months up to a few years, but usually resolve completely with closure of the growth plate. Surgery is rarely required.

Treatment Options for Pediatric Knee Pain

Rehabilitation and physical therapy might be the main focus in very mild cases, or after the use of other treatment modalities. An example might be Osgood Schlatter Disease, a condition that typically resolves eventually on its own, but for which definitive treatment is sometimes required. Osgood Schlatter consists of an injury to a growing area of bone at the top of the shin bone (the tibia) just below the knee. It occurs in active adolescents, especially during growth spurts. The injury causes pain and tenderness just below the knee, and might be associated with swelling. The condition is usually self limited, and resolves when the growing is finished. The main reason for treatment is to relieve pain and to avoid a prolonged period of impairment. In other instances, rehabilitation and physical therapy might be a prolonged process with the intention of avoiding a particular type of surgery, and in many cases it is a necessary step after surgery.

Treatments fall into the 3 categories above. The severity of the pain, the specific diagnosis, and the long term implications all have to be taken into account when treatment options are considered. In addition to discussing risks and benefits of specific treatments, it’s also vital to have a clear idea of the nature of the diagnosis, the predictive course, and long term implications.

The usual approach for treating pediatric knee pain is to start with non-invasive options. This might include ending or modifying activities at home, in physical education classes or in sports that cause knee pain. It could also mean a period of rest, the use of ice, some simple knee exercises or physical therapy. The goal in all cases is to make the knee pain go away. If these measures do not work, are too slow, or if the condition is potentially harmful, then surgery might be considered.

Non-surgical Approaches

Activity modification is recommended before considering any therapeutic intervention and it remains an important aspect of treatment. Participants in the consensus meeting agreed that children with patellofemoral pain should avoid activities which exacerbate their pain; this often involves ceasing or altering the inciting activity. There is speculation that patellofemoral pain is related to activity type and intensity in children with certain systematic reviews suggesting that issues such as activity type and volume of vigorous activity could be associated with patellofemoral pain.

Non-surgical approaches are typically recommended for the initial treatment of children with patellofemoral pain. The pain usually subsides with time (often months to a year). The most widely used tool for advising non-surgical treatment is a recent international 22-expert consensus statement. It provides a recommended algorithm and a graded (based on available evidence) list of non-surgical treatment for children with patellofemoral pain.

Surgical Interventions

Surgical interventions are a consideration for children with PFP if symptoms have failed to settle following an appropriate period of non-operative management, usually 3-6 months. Surgery is rarely considered prior to skeletal maturity due to the multifactorial nature of PFP and the potential for recurrence of symptoms post intervention. Alignment of anatomical changes with clinical symptoms is crucial for successful surgical management of PFP. Commonly, a range of pathology will be observed such as mal-tracking and tilt of the patella, soft tissue imbalance, anatomic predisposition, and in some cases, bony alignment issues. Treatment should be directed at the underlying cause of the PFP, and an individualized approach should be considered. The type of surgery which is indicated will vary depending on the pathology, severity of symptoms, specific demands of the child, and expectations of their guardians. Surgery may often involve a combination of techniques with a number of potential procedures being considered under each category.

Rehabilitation and Physical Therapy

Regaining full knee range of motion is important and can usually be achieved with maintenance of normal daily activities and the inclusion of specific exercises (such as stretching and mobilizations) as part of an overall rehabilitation program. Static stretching exercises should initially be used to increase flexibility of overly tight quadriceps and hamstring muscles. These are most effective when the muscle is warm and can be maintained for a period of 15-30 seconds. Overly aggressive stretching should be avoided, especially with young individuals, as this may exacerbate pain at the tibial tuberosity. High velocity stretching exercises or dynamic stretches where the muscle is stretched by moving the limb through a full range of motion are generally not used in the initial stages of rehabilitation for children with knee pain.

Both general and specific exercises are an important aspect of pediatric knee pain rehabilitation and usually occur in stages. Initially, the goal of treatment is to reduce pain and inflammation. This is followed by regaining knee range of motion and then progressively strengthening the knee and its dynamic stabilizers, such as the quadriceps (thigh) and hamstring (back of the thigh) muscles. It’s these muscle groups that are most likely to have become weakened and atrophied during episodes of knee pain. Research has shown that individuals with Jumper’s Knee have significantly less strength and endurance in the quadriceps muscles of their symptomatic knee compared to those with healthy knees. Similarly, children with Osgood-Schlatter disease have been shown to have significantly weaker quadriceps and hamstring muscle strength compared to a control group.

Finding a Knee Pain Specialist in Singapore

The first step to finding a knee pain specialist for your child involves researching qualified doctors in knee pain Singapore. A qualified knee pain specialist would have completed a pediatric medical or surgical training and has a certification in their area of specialty. In Singapore, you can check if the doctor is registered with the Singapore Medical Council and look out for KK (Koh Kock Leong) Hospital Service Awards that recognize outstanding individuals who have contributed to the healthcare service during their study period that was instituted by the Ministry of Health, Singapore. Other than that, the level of higher professional qualification such as a Masters of Medicine (MMed) in Orthopedics can also be considered. It is most ideal if you get in touch with a doctor that was recommended to you by someone who has recovered from the same condition. They are likely to have a better understanding and support for your child’s condition and would be in good standing to provide the best course of treatment. A good indicator would be their passion and knowledge in the field in managing or preventing the condition of your child. Another method to consider when finding a knee pain specialist would be to get a referral from another doctor you and your child trust. The doctors from Sports Clinic Services would usually refer patients to other qualified specialists who specialize in their patients’ condition.

Researching Qualified Specialists

Other than word of mouth recommendations, you can search for knee pain specialists on the internet from clinic/hospital websites or through search engines. Information on the specialist’s experiences and area of interests can be found at times on the internet, but not all websites have them. If it is available, make sure their experiences are in treating children’s knee problems and not adults. You do not want to waste time having to consult multiple specialists, each with different sub-specialties that do not treat your child’s specific knee problem, especially if it is a chronic one.

Obtain information about the specialist’s experiences with treating children’s knee problems from friends, relatives, school teachers, sports coaches, therapists, or family physicians that may have had an encounter with a similar case. Recommendations from sports physicians or physiotherapists will be the most valuable as they should be able to guide you to the correct specialist that treats your child’s specific knee problem. They may also be able to give you information about the type of rehab plan that your child may undergo after seeing the specialist. Make sure you find out about the experiences and whether their problem improved with the treatment of the recommended specialist.

Begin by generating a list of potential knee pain specialists you may want to visit. They can be from public or private hospitals or private clinics, sports institutes or physiotherapy practices. Do not be discouraged if some of them are difficult to find information on the internet. Get their contact if possible and give them a call to ask about their experiences with children’s knee problems. Note that some specialists may specifically only treat adult knee problems, so it would be best to verify it with the clinic/hospital. During the telephone call, you may also want to briefly describe your child’s knee problem and ask about their knowledge and experience with treating such problems in children with the specialist. Other questions you may want to consider asking are any subspecialty training with children’s knee problems (e.g. pediatric orthopedics or sports medicine), how often they see cases with children’s knee problems, and on average what proportion of it are knee injuries. Be aware that the receptionist may not always be able to answer your technical questions, but they usually would relay the message to the specialist and answer you back. A visit to this specialist may have to be done to get more concrete information about the specialist’s experiences with children’s knee problems.

Considering Recommendations and Reviews

Having a shortlist of specialists, it is time to make a decision. Besides information on the specialist’s credentials and working experience, the comfort level of the patient and parent is an important factor. Frequently, the best indication of whether or not this is the right doctor is subjective and hard to define. The most accepted way is the recommendation from a friend or relative. Unfortunately, pediatric knee pain and its related specialists are not very common in Singapore. Therefore, it is worthwhile asking around the local and expatriate community to see if anyone has a recommendation. This could come from other parents, family doctors, school nurse, or athletic coach. Any of these suggestions should be followed with the doctor investigating any relevant imaging and should be someone with an interest and experience in the management of adolescent knee conditions. Health grade and similar web listings provide a subjective numeral score of a particular doctor’s experience and success in managing specific conditions through feedback from patients and families, strict data collection, comparison, and extensive peer review. Unfortunately, this type of information is not readily available in Singapore.

Scheduling an Appointment

Parents should contact the potential knee pain specialist’s clinic to find out the procedures and the process for new patient appointments. Some knee pain specialists may require a physician’s referral, so the parent should clarify this before doing anything else. Some clinics may also require the patient to go through a physiotherapy session first or have an X-ray taken before the knee pain specialist can make an accurate diagnosis. Although all these scenarios may be a time-consuming process, it is always best to be under the guidance of the knee pain specialist from the start of the injury. At the same time, the parent should also find out the general availability of the knee pain specialist, i.e., how soon can an appointment be made. For some very busy knee pain specialists, there may be a substantial wait before an available appointment. A knee pain specialist with a long waiting list could mean that he is good at what he does, but in the interests of the child who has a recent knee injury, it would probably be best to find a knee pain specialist who is more readily available.

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