A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella
A 15-year-old male reports dull pain in both knees
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To prepare:
- By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
- Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
Case 3: Knee Pain
A 15–year–old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
With regard to the case study you were assigned:
- Review this week\’s Learning Resources, and consider the insights they provide about the case study.
- Consider what history would be necessary to collect from the patient in the case study you were assigned.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\’s condition. How would the results be used to make a diagnosis?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel\’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
- Chapter 22, “Musculoskeletal System”This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 22, “Lower Extremity Limb Pain” This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.
Chapter 24, “Low Back Pain (Acute)” The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 2, \”The Comprehensive History and Physical Exam\” (\”Muscle Strength Grading\”) (Previously read in Weeks 1, 2, 3, 4, and 5)
- Chapter 3, \”SOAP Notes\”This section explains the procedural knowledge needed to perform musculoskeletal procedures.
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Student checklist. In Seidel\’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel\’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Key points. In Seidel\’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel\’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., … Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane, C. C. (2014). Does physical activity influence the relationship between low back pain and obesity? The Spine Journal, 14(2), 209–216. doi:10.1016/j.spinee.2013.11.
010
Shiri, R., Solovieva, S., Husgafvel-Pursiainen, K., Telama, R., Yang, X., Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650. doi:10.1016/j.semarthrit.2012.
09.002
Document: Episodic/Focused SOAP Note Exemplar (Word document)
Document: Episodic/Focused SOAP Note Template (Word document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 13, “The Spine, Pelvis, and Extremities”
Expert Answer and Explanation
Knee Pain Episodic/Focused SOAP Note
Patient Information:
JD is a 15-year-old African American Male.
S.
CC “Dull pain in both knees for four days.”
HPI: JD is a 15-year-old African American Male who came to the hospital with complaints of dull pain in his both knees for the three days. He reports that he sometimes feels catching sensation under the patella and both knees often click. The pain started after playing basketball tournament three days ago. He has not applied any medication. The severity of the pain I 8/10.
Current Medications: No medications
Allergies: No allergies.
PMHx: No history of major medical conditions. Pneumonia and influenza vaccines are up to date.
Soc Hx: Denies tobacco or alcohol use. He is the only child in a middle-class family. He loves playing basketball.
Fam Hx: He is the only child in a family of three. Both parents are alive and healthy. Grandfather died of depression. He committed suicide. Grandmother is alive as has type II diabetes.
ROS:
GENERAL: No fatigue, weight loss, or fever.
HEENT: Eyes: No vision problems. Ears, Nose, Throat: No hearing problem, sneezing, runny nose, congestion, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No heart problems.
RESPIRATORY: No breathing problems.
MUSCULOSKELETAL: Knee pain.
HEMATOLOGIC: No anemia or bleeding.
O.
Physical exam:
Constitutional: General Appearance: Healthy adult with moderate distress. A+O+3, mucous membranes moist, flushed, answers questions properly. Vitals: BP 122/90; P 57; R 20; T 36.3; W 58kgs; H 157cm.
HEENT: Head: NC/AT. Eyes: Pupils are PERRL, extraocular movements intact; conjunctivae pink. Ears: Hearing intact, normal external appearance. Nose: Appears normal, clear mucus. Mouth: The are in good shape. Throat: No lesions or inflammation of the tonsils.
Skin: Normal color for ethnicity, dry, warm, with no rashes or lesions.
Cardiovascular: S1, S2 with regular rhythm and rate. No heart sounds.
Lungs: Chest walls symmetric. Lungs clear and bilateral. Regular respirations.
Knee: MRI shows ACL tear in both knees.
Diagnostic results: Diagnosis for knee musculoskeletal can be done using MRI or X-ray (Ball et al., 2019). The authors note that X-ray cannot see the ligaments, and in this case, MRI is recommended.
- X-ray: Pending
- MRI: Pending
A.
Differential Diagnoses
- Anterior Cruciate Ligament (ACL) Injury. The primary diagnosis for this ACL injury. ACL injury is a sprain or tear ACL, one of the major ligaments in the knee (Korakakis et al., 2019). The injury occurs mostly in sportspersons. The disease causes pain in the knee. It has been included as the primary diagnosis because the patient is a sportsperson and recently got injured during a game.
- Knee locking: Characteristics of knee locking include catching sensation, swelling of the affected knee, and pain with extension (Lee, Nixion, Chandratreya & Murray, 2017). The disease is not a primary diagnosis because the patient is no swelling in the knee.
- Osteochondritis Dissecans: OCD is a joint condition that occurs when blood is not enough in the end of the bone. It also causes pain in the knee, and that is why it has been included in the diagnosis.
- Juvenile idiopathic arthritis: JIA is the swelling of the joints. The disease occurs before a kid reaches 16 years (Ramanan et al., 2017). It causes joint pain, and that is why it has been included in the diagnosis.
- Repeated kneecap dislocation: Repeated patellar subluxation is the continued instability of the patellar, which causes knee pain.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel\’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Korakakis, V., Saretsky, M., Whiteley, R., Azzopardi, M. C., Klauznicer, J., Itani, A., … & Malliaropoulos, N. (2019). Translation into modern standard Arabic, cross-cultural adaptation and psychometric properties’ evaluation of the Lower Extremity Functional Scale (LEFS) in Arabic-speaking athletes with Anterior Cruciate Ligament (ACL) injury. PloS one, 14(6), e0217791. https://doi.org/10.1371/journal.pone.0217791
Lee, P. Y. F., Nixion, A., Chandratreya, A., & Murray, J. M. (2017). Synovial plica syndrome of the knee: a commonly overlooked cause of anterior knee pain. The Surgery Journal, 3(1), e9. doi: 10.1055/s-0037-1598047
Ramanan, A. V., Dick, A. D., Jones, A. P., McKay, A., Williamson, P. R., Compeyrot-Lacassagne, S., … & Beresford, M. W. (2017). Adalimumab plus methotrexate for uveitis in juvenile idiopathic arthritis. New England Journal of Medicine, 376(17), 1637-1646. https://www.nejm.org/doi/full/10.1056/NEJMoa1614160
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FAQs
What is Osgood-Schlatter disease?
Osgood-Schlatter disease is a condition that affects the growth plate of the tibia, which is a bone in the lower leg. It commonly occurs in children and adolescents who are active in sports or other physical activities that involve jumping, running, or other repetitive movements that put stress on the knee.
The condition is more common in boys than in girls and usually affects children between the ages of 10 and 15. However, it can also affect younger children and adults who are physically active.
Causes of Osgood-Schlatter disease
The exact cause of Osgood-Schlatter disease is not known. However, it is believed to be caused by repetitive stress on the growth plate of the tibia. This stress can be caused by activities such as running, jumping, and other sports that require a lot of knee movement.
In addition to physical activity, other factors that may contribute to the development of Osgood-Schlatter disease include rapid growth and hormonal changes during puberty.
Symptoms of Osgood-Schlatter disease
The most common symptom of Osgood-Schlatter disease is knee pain. The pain usually occurs below the kneecap and may worsen during physical activity or after prolonged periods of sitting or standing.
Other symptoms of Osgood-Schlatter disease include swelling and tenderness around the knee, as well as a bump or bony protrusion on the tibia, just below the kneecap.
Diagnosis of Osgood-Schlatter disease
To diagnose Osgood-Schlatter disease, a doctor will usually perform a physical exam and ask about the patient’s medical history and symptoms. X-rays or other imaging tests may also be ordered to confirm the diagnosis and rule out other conditions that may cause knee pain.
Treatment of Osgood-Schlatter disease
Treatment for Osgood-Schlatter disease usually involves managing the pain and reducing inflammation in the knee. This may include rest, ice, compression, and elevation of the affected leg.
Nonsteroidal anti-inflammatory drugs (NSAIDs) may also be prescribed to reduce pain and inflammation. In severe cases, a knee brace or cast may be recommended to immobilize the knee and allow it to heal.
Physical therapy may also be recommended to help strengthen the muscles around the knee and improve range of motion. In rare cases, surgery may be necessary to remove the bony protrusion on the tibia.
Prevention of Osgood-Schlatter disease
To prevent Osgood-Schlatter disease, children and adolescents should be encouraged to participate in sports and other physical activities in a safe and controlled manner. It is important to warm up before exercising and to stretch before and after physical activity to reduce the risk of injury.
Children and adolescents should also be encouraged to wear proper footwear that provides adequate support and cushioning for the feet and knees. They should also avoid activities that involve repetitive stress on the knee, such as running or jumping on hard surfaces.
Maintaining a healthy diet that includes calcium and vitamin D is also important for the growth and development of strong bones and muscles, which can help prevent injuries and conditions like Osgood-Schlatter disease.
Preventing and Managing Osgood-Schlatter Disease
Osgood-Schlatter disease is a common condition that affects young adolescents who participate in sports and other physical activities. This condition can cause pain and swelling in the knee, making it difficult for children and adolescents to participate in physical activities. In this article, we will discuss ways to prevent and manage Osgood-Schlatter disease.
Complications of Osgood-Schlatter Disease
If left untreated, Osgood-Schlatter disease can lead to complications such as:
- Persistent pain and swelling in the knee
- Limited range of motion in the knee
- Weakened muscles in the thigh and lower leg
- Development of a bony lump on the tibia
Home Remedies for Osgood-Schlatter Disease
There are several home remedies that can help manage the symptoms of Osgood-Schlatter disease:
- Rest: Taking a break from physical activity can help reduce pain and swelling in the knee.
- Ice: Applying ice to the knee for 15-20 minutes at a time, several times a day can help reduce pain and swelling.
- Compression: Using a compression bandage or knee brace can help reduce swelling and provide support to the knee.
- Elevation: Elevating the affected leg above the level of the heart can help reduce swelling.
Exercises for Osgood-Schlatter Disease
Stretching and strengthening exercises can help manage the symptoms of Osgood-Schlatter disease. These exercises should be done under the guidance of a healthcare professional or a physical therapist. Some of the exercises that can help manage the symptoms of Osgood-Schlatter disease include:
- Quadriceps stretches: These stretches can help improve flexibility in the thigh muscles and reduce tension on the knee.
- Straight leg raises: These exercises can help strengthen the thigh muscles and improve knee stability.
- Hamstring curls: These exercises can help strengthen the muscles in the back of the thigh and improve knee stability.
When to See a Doctor
If your child or adolescent experiences persistent pain and swelling in the knee, it is important to see a healthcare professional. A healthcare professional can perform a physical examination and recommend appropriate treatment options. In some cases, imaging tests such as X-rays or MRIs may be required to diagnose Osgood-Schlatter disease.
Conclusion
In conclusion, Osgood-Schlatter disease is a common condition among young athletes and active children, but it can also affect adults. Although it can be painful and limit physical activity, it is typically a self-limiting condition that can be managed through rest, ice, and physical therapy. Home remedies and exercises may also help alleviate symptoms and improve recovery. However, if symptoms persist or worsen, it is important to seek medical attention and undergo proper evaluation and treatment. By taking steps to prevent the condition and seeking appropriate care when necessary, individuals can minimize the impact of Osgood-Schlatter disease on their daily activities and overall health.
Remember, if you suspect you or your child may have Osgood-Schlatter disease, it is always best to consult a healthcare professional for proper diagnosis and treatment.
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