Knee pain: Helping families access care

An Athletic boy Holding her Painful Injured Knee

Many parents don’t hesitate to bring their child to the emergency department (ED) for orthopedic injuries, including knee conditions. In fact, many head straight for the ED without contacting their child’s pediatrician or primary care provider. However, many common knee conditions can be managed in the primary care office.

Read on for an at-a-glance guide to managing knee pain, and learn how partnering with a pediatric orthopedic specialist can help you help your patients. See how a particularly challenging case led to surgical innovation.

Managing overuse conditions

As young athletes specialize in single sports and single positions at younger ages and focus on year-round play, the incidence of overuse conditions of the knee is rising. Overuse conditions (patellar tendinitis, Osgood-Schlatter syndrome, Sinding Larsen Joahannsen syndrome, plica syndrome, iliotibial band syndrome, patellar femoral pain) should be treated with:

  • rest/activity moderation
  • frequent icing
  • NSAIDs
  • physical therapy

If the patient responds to treatment, she should be monitored in the pediatrician’s office. If not, consider X-rays to rule out Osteocondritis Dissecans and a referral to the Boston Children’s Hospital Orthopedic Urgent Care Clinic.

X-rays: A quick guide
X-rays to rule out Osteocondritis Dissecans should consist of four views (AP, lateral, tunnel/notch and sunrise/skyline). Trauma X-rays should include three views (AP, lateral, sunrise/skyline).

Managing acute knee injuries: Urgent Care

Acute injuries that should be referred to the Orthopedic Urgent Care Clinic or the ED include unreduced dislocation, obvious deformity, possible open fracture, high-energy mechanism, laceration possibly involving knee and signs of septic knee.

X-rays should be obtained for all significant trauma and referred if a fracture is shown.

Contusions can be treated with rest and activity limitation, and the patient should be referred to Orthopedic Urgent Care if she isn’t improving in 10-14 days.

Knee sprains should be treated with crutches and a knee immobilizer/hinged knee brace, and the patient should be referred to Urgent Care if she isn’t improving in 10-14 days.

Managing structural injuries: Orthopedic specialist

If structural injuries (ACL tear, MCL/LCL tear, meniscus tear or reduced patellar dislocation) are suspected, the patient care be treated with crutches and a knee immobilizer/hinged brace and referred to the Orthopedic Center in 10-14 days.

Learn more about the Boston Children’s Orthopedic Urgent Care Clinic.

Challenging case: Discoid meniscus with excessive knee pain and early arthritis leads to surgical innovation

Some patients with knee pain require ongoing orthopedic expertise.

meniscus transplant
MRI shows no meniscus on the lateral side, filled in with joint fluid, and a normal medial meniscus triangle on the medial side.

A 9-year-old female presented with a history of three prior surgeries for a lateral discoid meniscus. She complained of pain laterally, swelling and reduced function. The MRI revealed extensive loss of meniscal tissue and progressive cartilage damage.

Three possible management plans were presented to the patient’s parents.

  • Meniscus transplant could be delayed until the child’s growth plates had closed. However, that would force her to live with worsening pain for several more years and also likely lead to progression of osteoarthritis, at which point she would not be a candidate for meniscus transplant.
  • A second option would be a total knee replacement in her teens or 20s. This option also would leave the child in pain for 10 years or longer. A total knee replacement at a young age would wear out and require a replacement.
  • The third option was to perform an experimental meniscus transplant on a child with open growth plates. At the time, meniscus transplant had been performed in adult patients for approximately 10 years.

    meniscus transplant
    Intraoperative arthroscopy shows no meniscus and cartilage loss.

Meniscus transplant: Challenges

The family agreed to proceed with the meniscus transplant. The procedure brought three challenges.

  1. The surgery could not disturb the growth plate on the upper end of the tibia.
  2. Would the donor meniscus grow with the child?
  3. The donor tissue had to be sized for a 10-year-old, and pediatric donors are uncommon in tissue banks.

Several months after the initial consultation, suitable donor tissue was located, and the surgery was performed.

meniscus transplant
Transplanted meniscus

Meniscus transplant: Results

The meniscus transplant surgery was a success. The patient’s pain was reduced, her arthritis has not progressed and she has returned to moderate activity. Follow-up MRIs show the donor tissue has grown with the knee.

Since the first pediatric meniscus transplant in 2010, more than 20 surgeries have been performed at the Boston Children’s Hospital Orthopedic Center.