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Managing young athletes’ knee problems results in safer treatments

A surprising number of patellofemoral joint problems in female athletes are linked to childhood abuse, so obtain a complete history.

Issue: May 2005

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--- John A. Bergfeld

WASHINGTON — When adolescents play sports their knees are bound be affected by problems ranging from pain and limited disability to more severe conditions, like osteochondritis dissecans, growth plate fractures and stress fractures of the tibia, fibula and femur, according to John A. Bergfeld, MD, FACSM.

“Some of the most common and most perplexing problems occur with sports activity in adolescents, and particularly around the knee joint,” Bergfeld said in a recent presentation.

As far as diagnosing knee problems is concerned, Bergfeld reminded the audience that if a limping athlete appears to have a knee problem but the knee is normal upon exam, “think about the hip joint. Every year we have an adolescent referred to us for a knee problem, and they’ll have a slipped capital femoral epiphysis (SCFE).”

Bergfeld, who is at the Cleveland Clinic in Cleveland and is Sports Medicine Section Editor of Orthopedics Today, delivered these comments at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting, where he reviewed effective ways to manage many sports-related knee problems in young athletes.

Tips that Bergfeld offered for diagnosing and treating SCFE, which is fairly common, included an often absent trauma history, physical examination of the hip and obtaining a hip radiograph to diagnose SCFE. “Treatment is surgical stabilization,” he said.

Don’t stop that growth

An injury to the growth plate near the knee may go undetected, so clinicians must have a high index of suspicion and look for a history of problems in and about the knee joint. “It can often be missed because it’s very subtle,” Bergfeld noted.

If the growth plate was fractured, stressing the bone at the suspected injury site during the physical exam produces pain. Standing or other stress radiographs may further aid in diagnosis.

Those adolescent athletes with stress fractures of the tibia, fibula or femur typically have a history of overusing their knee joints, either from too much training or performing repetitive activities like long distance running. A stress fracture occurs when “the physiological capacity of the bone is being exceeded. … There are all sorts of variations in the adolescent. If it’s in the female adolescent, maybe a little bit older, dietary and menstrual history are important for us as orthopedists to do,” he said.

Modify activity with OCD

Knee osteochondritis dissecans (OCD) treatment is based on the patient’s skeletal maturity and can be done open or arthroscopically. Bergfeld said, “In the skeletally immature, there’s a 60% to 75% chance of healing with a simple modification of activity.” But since modifying kids’ activities is hard, he recommended putting the child in a knee immobilizer not as a treatment, but to remind him or her to control all activity.

Computed tomography scans with contrast have proven quite effective for diagnosing OCD because it clearly reveals any fluid build-up behind the lesion. The lesion may be drilled. Loose fragments may be fixed with metal or bioabsorbable screws. A defect may be filled by autogenous OATS procedure. Occasionally a large defect may require an osteochondral allograft.

Anterior knee pain is common in active children. Patellar malalignment, subluxation and dislocation are not uncommon. Not all anterior knee pain can be resolved with a surgical procedure. In fact, persistent pain after failed patellofemoral surgery is also not uncommon. A clinic held for patients with failed patellofemoral surgery at Bergfeld’s hospital, under the direction of Jack Andrish, MD, revealed that 89% of the 57 patients were girls; 26% were bilateral. More importantly, “42% suffered some form of childhood abuse: 23% physical and 19% sexual abuse.” Physical training helps improve symptoms; only 25% of all patients needed additional surgery, Bergfeld said.

Tanner staging

Lastly, when repairing ACL tears in adolescent athletes. “I think it’s worthwhile trying nonsurgical treatment in these very young 10- and 11-year-old players.” But if the child continues to be unstable, then reconstruction using hamstring tendon through small drill holes may be used even in the skeletally immature.

For more information:

• Bergfeld JA. Knee injuries in the skeletally immature: Prevention and treatment. ICL#211. Presented at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting. Feb. 23-27, 2005. Washington.