From the Guidelines
When evaluating knee pain in pediatric patients, a thorough history and physical examination are essential for accurate diagnosis, and radiographs may be appropriate for the initial imaging of patients 5 years of age or older for the evaluation of a fall or acute twisting trauma to the knee when at least one of the following is present: focal tenderness, effusion, inability to bear weight, as recommended by the American College of Radiology 1.
Key Components of History and Physical Examination
- Begin by asking about the onset of pain (sudden versus gradual), duration, location, severity, and any precipitating factors such as trauma or overuse activities.
- Inquire about aggravating and alleviating factors, including whether the pain worsens with activity or improves with rest.
- Ask about associated symptoms like swelling, locking, giving way, or limited range of motion.
- A comprehensive review of the child's developmental history, growth patterns, sports participation, and family history of musculoskeletal conditions is important.
Physical Examination Approach
- Observe the child's gait and stance, inspect for deformity, swelling, or erythema, and palpate for areas of tenderness, particularly around the growth plates, joint line, and patellar region.
- Assess range of motion, stability testing (including ligament integrity), and special tests such as the patellar apprehension test or McMurray test as appropriate for the child's age.
- Compare findings with the unaffected knee.
Importance of Age-Appropriate Assessment
- Children's presenting symptoms often differ from adults, and growth-related conditions are unique to this population, making age-appropriate assessment crucial for proper diagnosis and management.
- The approach to history and examination should be tailored to the child's age and developmental stage, as recommended by recent guidelines 1.
Common Pediatric Knee Conditions
- Osgood-Schlatter disease
- Patellofemoral pain syndrome
- Patellar instability
- Growth plate injuries
- Juvenile arthritis These conditions can be differentiated through a systematic approach to history and physical examination, and appropriate imaging studies, such as radiographs or MRI, may be necessary to confirm the diagnosis, as suggested by recent studies 1.
From the Research
Approach to History and Examination
The approach to history and examination of knee pain in pediatric patients involves a thorough and careful evaluation to determine the underlying cause of the pain.
- A comprehensive history is essential to identify the potential cause of knee pain, including information about the onset, duration, and location of the pain, as well as any associated symptoms or trauma 2.
- A detailed physical examination is also crucial, including an assessment of the knee joint, surrounding muscles, and hip joint, as knee pain can sometimes be referred from the hip 3, 2.
- The evaluation should also consider the patient's age, activity level, and medical history, as certain conditions are more common in specific age groups or populations 4, 5.
Key Components of the Examination
The physical examination of a pediatric patient with knee pain should include:
- Inspection of the knee joint and surrounding tissues for signs of swelling, redness, or deformity 5.
- Palpation of the knee joint and surrounding muscles to assess for tenderness or masses 5.
- Assessment of range of motion and joint stability 5.
- Evaluation of the hip joint, as hip pathology can sometimes present with knee pain 3, 2.
Diagnostic Considerations
The diagnosis of knee pain in pediatric patients should consider a range of potential causes, including:
- Overuse or overload syndromes, such as patellofemoral pain or osteochondritis dissecans 4, 6.
- Anatomical abnormalities, such as discoid meniscus or plica syndrome 6.
- Inflammatory or infectious conditions, such as septic arthritis or osteomyelitis 2.
- Traumatic injuries, such as fractures or ligament sprains 5.