My child has knee pain – should I be concerned? Can pain in your child’s knee be just growing pains or would a physiotherapy assessment be useful?
Children are not merely small adults they have structurally different anatomy that accounts for characteristically different injuries in comparison to adults. In simple terms, their bodies are still developing so they have unfused growth plates (Physis) and apophyses (ligament and tendon attachments onto bone) that largely determine the difference in injuries.
There are also some more resilient features of the developing skeleton. Namely, the long bones in children are better able to absorb loads and deform, which means fractures are less likely here. The articular (joint) cartilage is thicker and has a greater ability to heal. In summary, the growing skeleton reacts differently to loading than the skeletally mature skeleton, resulting in the Physes and the apophyses being more prone to injury.
So, we have a child who is growing and developing and who is now participating in sports, some recreational and some on a competitive level. That leads us on to what kind of injuries we can expect to see in children and adolescents as they participate in more and more sports and some on a higher level as they get older. We are going to discuss one of the most common areas of injury in young athletes and children, being the knee.
Starting off with apophyseal injuries of the knee, we commonly see Osgood Schlatter disease and Sinding-Larsen-disease in children. A reminder that the apophysis is the attachment point of tendons and ligaments to the bone, which have not ossified yet in children so they are softer and more prone to injury which can be acute or chronic. Osgood Schlatters disease in a traction apophysitis that causes localised pain and mild swelling over the tibial tuberosity (below the knee), which is the insertion of the patella tendon.
It is common in sports that involve running and jumping (i.e. soccer) and affects young athletes between the ages of 11 to 15. The pain is aggravated by exercise and better with rest. The condition may last for two years but for the vast majority of symptoms will subside once bony fusion of the tibial tubercle has occurred.
Sinding-Larsen-Johansson disease is a very similar condition, but it affects the inferior pole of the patella (kneecap), at the superior attachment of the patella tendon. Management is activity modification and a reduction in training load, but the athlete does not have to stop sport. Physiotherapy guides the management with athlete specific advice for activity and training load modification as well as treatment for symptomatic relief.
Meniscal Injuries can also occur in children and adolescents but in the children the menisci have better blood supply and so the healing potential is much better. Meniscal injuries are often associated with anterior cruciate ligament (ACL) injuries, which must be assessed. ACL injuries are usually characterised by a twisting injury in sport which can include injury of the meniscus. The incidence of ACL injuries in children and adolescents has been becoming more prevalent.
Unfortunately, there are poor long-term outcomes of non-surgical and surgical intervention with high rates of re-injury and post-traumatic osteoarthritis. Therefore, injury prevention programmes like the FIFA 11+ Kids should be incorporated into training to prevent these and other serious injuries in children.
This article is the first in a series of three.
To book an assessment with a physiotherapist, contact Michelle at 031 765 8898.
References
• Stracciolini A, Casciano R, Levey Friedman H, Meehan WP, Micheli LJ. Pediatric Sports Injuries: An Age Comparison of Children Versus Adolescents. The American Journal of Sports Medicine. 2013;41(8):1922-1929. doi:10.1177/0363546513490644
• Rössler, R., Verhagen, E., Rommers, N., Dvorak, J., Junge, A., Lichtenstein, E., Donath, L. and Faude, O., 2019. Comparison of the ‘11+ Kids’ injury prevention programme and a regular warmup in children’s football (soccer): a cost effectiveness analysis. British journal of sports medicine, 53(5), pp.309-314.
• Ardern CL, Ekås GR, Grindem H, et al, 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. British Journal of Sports Medicine 2018;52:422-438.
• Edmonds, E.W., Polousky, J. A review of knowledge in osteochondritis dissecans: 123 years of minimal evolution from konig to the ROCK study group. Clin Orthop Relat Res. 2013; 471(4):1118-1126.
• Kocher, M.S., Tucker, R., Ganley, T.J., Flynn, J.M. Management of osteochondritis dissecans of the knee: Current concepts review. Am J Sports Med. 2006; 34(7):1181- 1191.
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