CLINICAL CASES - Case 4

A patient develops anterior knee pain during her adolescent growth spurt.

First published 2018, and reviewed August 2023 by Dr Sheila Strover (Clinical Editor)

 

Adolescent Anterior Knee Pain (AKP), insidious onset, varsity level track athlete

AKP associated with overuse, exacerbated by lateral release.

This female patient presented at 14, a high-performance varsity athlete, involved in cross-country running and track. As she entered her growth spurt at the age of 11, she developed left knee pain insidiously. There was no acute injury and she did not change her training pattern for running. She was unable to perform athletically in the spring of 2005 because of AKP . Symptoms included a parapatellar ache with radiation medially, crunching and snapping. Conservative management failed.

She underwent lateral release in Mar 2006 in another center in another American city. Her treating surgeon subsequently offered re-alignment surgery when she did not improve. She was seen 19 months later, and 3 years after onset of AKP, for a second opinion after her father communicated with me after viewing our informational website. If anything, her symptoms had been exacerbated following this surgery. She had pain with sitting, transiently worse when she arose from sitting, a catch in the knee with walking, and occasional swelling.

Examination

Examination showed generalized ligamentous laxity, the scar post-lateral release with marked irritation at the margins and a palpable gap in the underlying fascia, sub-patellar crepitus, marked apprehension with any patellar manipulation, tracking identical to the other side, slight recurvatum and varus.

Investigations

Plain films and an MRI showed no pathology.

Surgery

Arthroscopic findings demonstrated a separate plica of normal structure, and some fibrosis at the lower end of the lateral release. There was non-isometric mechanical behavior of the IPP as described above, taut approaching full flexion, lax in mid flexion, becoming taut in extension at 15° - 20° as the IPP contacted the apex of the notch, drawing the fat pad tightly against the femur, obscuring view. The separate IPP was released, and the fibrosis debrided. The fat pad was liberated, with no remaining attachment to the notch. The outcome was successful, with the patient obtaining a track and field scholarship for college, competing at the intercollegiate level.

Outcome

Patient’s comment from website:

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