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Case study: teen with knee pain
This is an excerpt from Clinical Guide to Surface Palpation 2nd Edition With HKPropel Online Video, A by Michael Masaracchio & Chana Frommer.
History
A 14-year-old female presents to your office complaining of left knee pain for 1 month. She states that the pain is localized to the front of her knee, is intermittent, and occurs with using stairs, prolonged sitting with the knee bent, and running while playing soccer. She does not recall a traumatic incident. She lives in a duplex apartment with her family, with eight stairs into the building and the entrance to her apartment on the entry level. She plays soccer, and the team practices four times a week for 2 hours, with games on the weekends.
- Based on the subjective information only, what are the three most likely diagnoses?
Examination
- Based on the subjective and objective information together, what are the two most likely diagnoses? Give your rationale for eliminating the third diagnosis.
- What structures should you palpate on this patient based on your differential diagnoses?
- Given all the information presented, what would you expect to find on palpation of those structures?
Case Solution and Discussion
Potential Diagnoses Based on History
- Infrapatellar fat pad irritation
- Patellar tendonitis
- Patellofemoral pain syndrome
Potential Diagnoses Based on History and Examination
- Patellar tendonitis
- Patellofemoral pain syndrome
- Infrapatellar fat pad irritation: The location of pain and the pain occurring with prolonged sitting, in conjunction with the positive special tests, make this diagnosis unlikely. However, it cannot be completely ruled out at this point of the exam.
Structures to Be Palpated
- Patellar tendon
- Tibial tuberosity
- Adductor tubercle
- Infrapatellar fat pad*
*Note: This diagnosis relies heavily on the palpatory exam and cannot be completely ruled out until that has been completed. Therefore, the infrapatellar fat pad remains one of the structures to be palpated to affirm elimination of the possibility of this diagnosis.
Palpation Findings
- Tenderness to palpation of the left patellar tendon (proximally)
- No tenderness to palpation of the tibial tuberosity and distal patellar tendon
- Tenderness to palpation of the left adductor tubercle
- No tenderness to palpation of the left infrapatellar fat pad
Clinical Reasoning
- Patellar tendonitis: The patient’s report of the location and occurrence of pain in her knee; the gait deviations; the positive special tests; and the weakness of her left quadriceps, hip abductors, and external rotators—as well as the structures that are tender to palpation—can be consistent with patellar tendonitis. While there is a strong possibility that this is the diagnosis, the reason it is not our primary diagnosis is the lack of tenderness to palpation throughout the entire patellar tendon. However, be aware that patellar tendonitis can occur in conjunction with patellofemoral pain syndrome.
- Patellofemoral pain syndrome: The patient’s report of the location and occurrence of pain in her knee; gait deviations; positive special tests; and weakness of her left quadriceps, left abductors, and external rotators—along with the structures that are tender to palpation—all indicate patellofemoral pain syndrome. In addition, her posture (left subtalar joint pronation and genu recurvatum) and activity level put her at risk for patellofemoral pain syndrome.
Case Study Questions
- What information do the palpation findings of the case give the clinician? How can this information be incorporated in the clinical decision-making process?
- Think about how the examination findings (subjective and objective) lead to the differential diagnosis. What might you do differently?
- Discuss the role of patient education when treating and managing a female teenager.
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