Common Knee Injuries in Student Athletes – PediaCast CME 102

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Description

  • The sports medicine team visits the studio as we consider common knee injuries in student athletes. We explore the cause, diagnosis, management, and prevention of patellofemoral pain syndrome, Osgood-Schlatter disease, Sinding-Larsen-Johansson syndrome, meniscal tears, patellar dislocation, and your everyday sprains and strains. We hope you can join us!

Instructions to obtain CME/CE Credit

  1. Read this information page.
  2. Listen to the podcast.
  3. Complete the post-test at Nationwide Children’s CloudCME.

Topics

  • Knee Injuries
  • Patellofemoral Pain Syndrome
  • Osgood-Schlatter Disease
  • Sinding-Larsen-Johansson Syndrome
  • Meniscal Tears
  • ACL Injuries
  • Patellar Dislocation
  • Sprains and Strains

Presenters

Learning Objectives

At the end of this activity, participants should be able to:

  1. Define patellofemoral pain syndrome and describe its clinical findings.
  2. Explain why Osgood-Schlatter disease and Sinding-Larsen-Johansson syndrome are only seen in younger athletes.
  3. State the most common injury mechanism for meniscal injuries.
  4. Counsel families on factors that may lead to recurrent patellar dislocation.

Links

Disclosure Statement

  • No one in a position to control content has any relationships with commercial interests.

Commercial Support

  • Nationwide Children’s has not received any commercial support for this activity.

CME/CE Information

  • In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)
  • Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.
  • As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.
  • Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.

Contact Us

  • CMEOffice@nationwidechildrens.org

 

Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Sports Medicine at Nationwide Children's Hospital. Hello, everyone, and welcome once again to PediaCast CME. It is a continuing medical education podcast for healthcare providers.

This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 102.

We're calling this one Common Knee Injuries in Student Athletes. I want to welcome all of you to the program. Today we are covering common knee injuries in student athletes, and I think it's a good time of the year to do it because basketball season is underway and will be ongoing throughout the winter.

Knee injuries are actually fairly common in basketball players, but also in lots of other sports as well. Not only are there injuries from play, but we also see strains and sprains, the patellofemoral pain syndrome, Osgood-Schlatter's disease, the Sinding-Larsen-Johansson syndrome, meniscal tears, patellar dislocation, just lots of things that can go wrong with the knee. Often, they just present kind of the same with just knee pain and limited ability to move the knee and some swelling.

So how do you figure out what exactly is going on? And then we'll also cover the prevention and management of these common knee injuries. Of course, in our usual PediaCast fashion, we have a couple of terrific guests joining us this week.

Benjamin Lee is with Physical Therapy at Nationwide Children's Hospital, and Dr. Drew Duerson is with Sports Medicine, also at Nationwide Children's. And we have a guest host leading the conversation today. Eric Leighton is back.

He is a certified athletic trainer with our hospital and the coordinator for sports medicine topics on PediaCast. He also leads the Functional Rehabilitation Program at Nationwide Children's Hospital. So, it's going to be a great conversation, and we'll get to all of them momentarily.

First, I do want to remind you that after listening to this episode, be sure to claim your free Category 1 CME credit. Really easy to do. Just head over to the show notes for this episode at PediaCastCME.org.

It's episode 102, and you'll find a link to the post-test in the show notes. Follow that link to Cloud CME, click on the Materials tab, and then taken past the post-test and the Category 1 credit is yours, and it's absolutely free. We do offer credit to many pediatric professionals, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists even.

And since Nationwide Children's is jointly accredited by many professional organizations, in fact, all of those that I mentioned, it's likely we offer the exact credits you need to fulfill your state's continuing medical education requirements. Of course, you want to be sure the content of the episode matches your scope of practice. Complete details are available at PediaCastCME.org.

Also want to remind you the information presented in our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. Also, your use of this audio program is subject to the PediaCast CME Terms of Use Agreement, which you can find at PediaCastCME.org.

So, let's take a quick break. We'll get our panel of sports medicine experts settled into the studio, and then we will be back to talk about common knee injuries in student-athletes. It's coming up right after this.

[Dr Mike Patrick]
Benjamin Lee is a physical therapist with sports and orthopedic therapies at Nationwide Children's Hospital, and Dr. Drew Duerson is a sports medicine physician and an assistant professor of pediatrics at The Ohio State University College of Medicine. Both have a passion for preventing and treating knee injuries in student-athletes. That's what they're here to talk about today, but before we jump into that, let's offer a warm PediaCast welcome to our guests.

Thank you both so much for stopping by today.

[Benjamin Lee]
Thanks for having me, Dr. Mike. 

[Dr Drew Duerson]
Yeah, pleasure to be here. Thank you.

[Dr Mike Patrick]
Yeah, we are really happy you guys are able to take time out of your busy schedules and be here. We also have a guest host leading the conversation today. Eric Leighton is a certified athletic trainer and leads the Functional Rehabilitation Department at our hospital, and he is the PediaCast coordinator for sports medicine topics on our podcast.

Thanks for all you do, Eric. And with that, I will hand the reins over to you.

[Eric Leighton]
All right. Thank you so much, Dr. Mike, and thank you for allowing us to come on and talk today and bring us into the studio. So as Dr. Mike mentioned, knee injuries. Knee injuries is probably one of the more common things we see in sports medicine. And of course, as you know, it can be a whole host of things. So today we're going to delve into some of the more common and maybe even some of the less common diagnoses or things we may see in the clinic and in rehabilitation.

So, I'm just going to jump right in. Ben, I'm going to come to you first. What are some of the most common knee injuries that we do see in clinic or in rehabilitation?

[Benjamin Lee]
Yeah, we see a whole variety of injuries in the clinic and rehab. Just to simplify, there are two main categories of injuries that we see. First would be the post-operative injuries.

These would be injuries from athletes or adolescents coming out of a surgery. And the second category would be non-operative, so injuries that do not involve a surgery. For our post-operative injuries, some common ones we see are ligament and meniscal repairs, meniscectomies, when they cut out a piece of tissue inside the knee that has been damaged, patellar instability surgeries.

These are common when individuals have recurrent patellar dislocations, and they have to undergo a surgery where they can help stabilize that kneecap. We also see osteochondral surgeries, which may include a removal of a bony loose body or a microfracture, as well as some fracture repairs. Mainly we see open reduction internal fixations of the proximal tibia or distal femur.

And with these post-operative injuries, the timeline of recovery will vary based on the type of surgery the kid or the adolescent went through, but this is typically a longer course of rehab compared to our non-operative injuries. Non-operative injuries can include patellofemoral syndrome. This is typically described as pain around or behind an individual's kneecap.

We also see growth plate injuries such as Osgood slaughter disease or Sinding-Larsen-Johansson disease, especially in our growing kiddos as they hit that peak height velocity in their development. We also see patellar instability that does not require surgery, so kids that often dislocate their kneecap, but doctors determine that it's best to go through a conservative route as opposed to a surgical route to start off. And we also see tendinopathies.

This would include the patellar tendon at the bottom of the kneecap, as well as the distal hamstring tendon, typically on the outside and back of your knee. And we also see some strains and sprains of various muscles and ligaments. So that was a lot, I know, but I know we're going to dive into a little bit more detail about each individual type of injury.

[Eric Leighton]
Yeah, and one of the points you made in there specifically with growth plates, you know, being that growth plate injuries, especially with our population dealing in pediatrics, we're not dealing, as I always tell people, we're not just dealing with short adults, we're dealing with kids, you know, for quite a while until they get old enough. It's a whole different critter. You've got to consider those growth plates.

So, there's things that you'll do in clinic that we can do in rehab that they'll have to do in surgery, but they are completely different from how I would treat an adult just because of that, those growth centers and growth plates that we have to worry about. So actually, kind of going off of one of the last ones there, so as you mentioned, Ben, we're going to kind of delve into some more detail on each of these. So, Drew, of those common ones, one of the ones that, you know, I think most people would see as real common and we see out there out and about a lot are the strains and sprains tend to be one of the most common.

And sometimes they can also be seen as sort of a lesser injury, right? People may not give it as much credit or credence as they need. So, when you see that come into clinic, when you diagnose a sprain or strain, what are the things that we need to make sure that we don't miss about that?

[Dr Drew Duerson]
Sure. So, you know, first thing, Eric, I think we need to keep strains and sprains separate. So, when we say a strain, we're typically talking about a muscle tendon or a musculotendinous unit.

So, I see that mistake often made. And then a sprain is going to be more of a ligamentous structure. So, trying to keep those two separate is important.

And then like you said, there's a spectrum of injury. A lot of these are going to be mild injuries that we see, but we do not want to miss the higher grades strains and sprains because with those injuries become, you know, very significant issues for our athletes especially and when they're trying to return to play. And a lot of times when we see high grade, we'll use sprains as an example, especially of the knee, often that comes with other injuries.

It's typically not just an isolated thing. It can be, but whenever I see, we'll say a lateral collateral ligament injury of the knee by itself is very, very uncommon, I think. But when I see that and suspect that based off my history and exam, you know, that takes my attention to more interarticular structures and namely the menisci.

So, I want to make sure I'm not missing a meniscal tear that may be associated with that sprain. And then on the high, you know, end of the spectrum for strains, you know, you don't want to miss a quadriceps tendon tear or a patellar tendon tear. We fortunately do not see these often in our skeletally immature athletes, but they do come occasionally.

And those are acute injuries that cannot be missed because they need our, you know, attention right away and often it's a surgical intervention that's needed. So, I think we need to be careful when we use these terms, and we don't want to just call every knee injury that comes into clinic just a knee strain or sprain. We need to be more specific, you know, try to really pinpoint the actual ligament or actual tendon that's involved and then the severity of that injury.

So, we don't miss anything.

[Eric Leighton]
Yeah. And as you mentioned, Drew, too, I mean, as you look for these injuries, as with any joint, but specifically a significantly sized joint like that to do damage to it, to do damage to the MCL, for instance, you're talking about a very high-speed torque moment, a lot of angle change. So, they can't just live by themselves.

There's a lot of times there's multiple things hiding in there with it.

[Dr Mike Patrick]
Just if I could jump in real quick from the primary care docs point of view, is there a way to narrow that down without necessarily having great expertise on the knee or is this something like you get an MRI and you find out what area is inflamed and that's how you know, or is there something on the clinical exam you can do to tease those out?

[Dr Drew Duerson]
Yeah, I'll take a stab at that. You know, I think first of all, just knowing your anatomy, which we all learned it really well in medical school, but then if you don't use it, you lose it. So, I think maybe a refresher on your musculoskeletal anatomy around the knee and being very intentional about your palpatory exam when you're going through your landmarks, make sure you know what you're palpating.

And if you don't know what you're palpating, you know, maybe that's where a tool like a point of care ultrasound comes into play where you can actually see what you're palpating as you're doing your exam. And then, you know, obviously, I think checking these ligaments and tendons for their integrity is very, very important. It's one thing to know where the lateral collateral ligament lives, but you then need to be able to put stress on it.

So being able to do your special tests to be able to maybe then dive into the severity of that injury. Is there, you know, laxity with the DE in full extension? You know, that's going to make me think more of a high-grade injury.

If there's laxity only with a slight flexion of the knee, then maybe it's more of a mild injury. So, I think, you know, really practicing your exam and getting good at it and, you know, sticking to, you know, own protocol as you go through a knee exam, so you don't miss things is very important.

[Eric Leighton]
Yeah, it's very important. And as again, as we talked about, you know, it's they don't just live by themselves. So, you take a high impact that happens to get one of those ligamented structures.

Well, I'm going to go back to you on this one, Drew. So, contusions, you know, generally in high-impact sports, really any sports, there's always a chance for that, whether it's a collision sport like football or a contact sport like soccer and basketball, but those contusions can sometimes also be seen as less like, ah, you got a bruise, you're a little black and blue, so what? But we know those can leave some significant damage and possible dysfunction.

So, what are the issues that we can find there?

[Dr Drew Duerson]
Yes, you're right. You know, I think when you have a contusion, there's often something else. So, you know, for me, when I see a knee that's been, you know, put through a direct impact and, you know, most likely going to diagnose a contusion, I want to know what actually is contused.

You know, is it all soft tissue? Is there any bony involvement? Is there any, you know, particular cartilage involvement?

Because as we get deeper, you know, we see more pain, disability, you know, return to play becomes, you know, a bigger issue too. And then one of the, you know, very common things that we'll see with soft tissue contusions is a hematoma, which is going to be a collection of blood that's going to typically live within the muscle or nearby. And that can be, you know, one of those things that really cause the patient to struggle to recover in rehab, especially some of our larger hematomas.

And that may make us, you know, lean towards being a bit more aggressive with our treatment, where we may want to consider an aspiration of that hematoma. Our body will resolve that hematoma over time, but it may take a long time. And if we can aspirate that hematoma, that may speed up the recovery for our young patients and especially our athletes get them back on the court or field a little bit quicker.

[Eric Leighton]
Hey, Ben, I'm coming to you. All right, PFS, patella femoral syndrome, the old term. I know there's other terms for it too, which definitely remind us of that.

This is one of those injuries that I know from the rehab side, it feels like this is one of the ones that always feels like it takes quite a while to get over. What is it about that kneecap pain, about the patellar pain that is just so debilitating?

[Benjamin Lee]
Yeah, a couple of reasons. Patellar femoral syndrome, like you said, like I've got so many kids on my caseload right now with that kneecap pain. There are so many varying degrees of severity and like you said, it can be very debilitating, it can be hard to shake off.

A couple of big reasons stand out to me as to why that is the case. First, that patella femoral syndrome can have many aspects that affect everyday life, everyday tasks such as walking, squatting, going up and down the stairs, running and most sport movement. And that's because the main clinical sign we see of this is pain with the knee flexion and weight bearing.

So, whenever that knee is bent and we're putting weight through that leg, that's when that kneecap typically hurts quite a fair bit. If we think about those tasks of everyday life, walking, squatting, going up and down the stairs, with kids right now in basketball season, jumping and landing and jumping and landing on that knee, there's just every single day you get so many reps of that painful or provoking movement that it can be very, very debilitating over time. The second thing I would say is that patellar femoral syndrome is quite an indiscreet injury.

It sort of creeps up on kids over time, and it can be hard to identify for kids and parents. A typical story that I'll hear right now in clinic is, man, I started to feel a little bit of knee pain during soccer season, kind of in the middle of the fall, and then just started to get a little bit worse during playoffs when we were ramping up more. And then, hey, I just started basketball, and we were running and doing conditioning constantly and jumping and landing, and it's been hurting more and more.

And now I'm like, I can't play basketball without like a 5, 6, 7 out of 10 pain. And so that like gradual, slow, creeping up progress can be hard for kids to initially identify as opposed to like a contusion that Drew was talking about where I landed on my knee, I hurt it, okay, now my knee hurts, right? And so, it can be hard to have a sense of control over it as well.

When that pain kind of creeps up, it's slow, it's gradual, it gets worse and worse, and then it starts affecting pretty much every movement or part of their life. It can be very debilitating. Luckily, with a good rehab program, we can resolve some of those deficits depending on what we see, working on a kiddo's flexibility, their strength, their movement literacy, and then just modifying some of their activities can go a long way.

But reversing that cycle and kind of coming down that hill of pain can take a while, and it has to take some consistency as well as some discipline for kids to kind of restrain themselves from doing too much and follow the rehab plan.

[Eric Leighton]
Yeah, the rehab plan is always a tough one.

[Dr Drew Duerson]
Drew? I was just going to comment, we see this all the time in our clinics. And when we tell a patient that you have patellofemoral pain or patellofemoral pain syndrome, often the family, especially the parents will say, oh no, is this something that's going to affect my child forever?

And this is one of those diagnoses that we see span across all ages. And I try to be optimistic, but I give that to the families, a little bit of ammo to say, hey, when you go see my physical therapy friend, like Ben, he's going to teach you a lot of great exercises that may make your knee feel better now, but what's going to be most important so this patellofemoral pain doesn't come right back next season or next year, next decade, is you got to maintain these exercises.

You got to continue to do these flexibility and strength exercises, really work it into a routine.

[Eric Leighton]
Yeah, exactly. Keeping up with the HEP, I tell the kids all the time, you go cold turkey on my HEP, I'm going to see you back in six months for the exact same problem. And yeah, it is one of those ones that tends to linger.

I've always told them, I said, it can linger for a minute. If you remember your anatomy, like Drew was talking about, if you don't use it very often, but from that anatomy with that extensor mechanism, the patella being part of the whole extensor, you use it for everything. So, I always kind of relate it to the patients and the parents and say, it's like poking a bruise, expecting the bruise to get better.

[Benjamin Lee]
Yeah. And that piece of education is so important, right? Like making sure kids and parents understand what is going on and what they need to do to resolve those deficits.

It can just give them so much more of a locus of control over their pain and their injury. And that can just go a long way in terms of not just resolving the pain right now, but in terms of the long-term, like Drew was mentioning in the future as well. Right.

All right.

[Eric Leighton]
Moving forward, kind of staying within that extensor mechanism, actually going from the quad down to the tibia. So, Drew, one of the most classic quote-unquote kid knee pain issues that front knee pain are Osgood-Schlatter's disease or Sinding-Larsen-Johansson, OSD and SLJ. Why is this just such a growing issue?

Why do we see this so much more in kids?

[Dr Drew Duerson]
Yeah. So, these eponyms are, you know, very common causes of anterior knee pain in only the skeletally immature athlete. So once that apophysis, which is just another fancy name for a secondary ossification center where a tendon attaches to bone, once that closes, then this goes away.

So, we only see this in our young patients. And I think it's, you know, like you said, very, very common. And we see it during these growth spurts, especially because we know that our skeleton grows at a very rapid pace and sometimes our muscle and tendons don't quite keep up.

So, we see a lot of inflexibility in our adolescent patients. And those are, you know, one of the key risk factors for these two conditions. And this, just like patellofemoral syndrome, you know, when you tell a family, your kid has Osgood-Schlatter disease or Sinding-Larsen-Johansson disease, you know, that really catches them off guard.

They're like, oh no, what is that? Because it sounds a lot worse than it is. Fortunately for these growing athletes, these are very, very many diagnoses that we can treat conservatively.

And I try to be, again, optimistic with the family and just use that as a little bit of a motivation though to, you know, really buy into the therapy and the home exercises, focusing especially on the flexibility. You know, we really have to get our young athletes stretching and stretching the right way and doing it very consistently every day.

[Eric Leighton]
Yeah. So, sticking with the kneecap, all right, with the patella, instead of just the more of the overuse and the growing issues, kind of shifting a bit more traumatic or significantly more traumatic. Ben, patellar subluxations and dislocations, which like I said, we know they can be traumatic.

So, from your experience, what are some of the best exam points and then treatments once we've gotten to that?

[Benjamin Lee]
Yeah. As far as exam points go, there are many different things we can look for. First of all, looking at mobility, range of motion, also looking at swelling and seeing what that looks like.

Imaging findings can also be very important. Certain ratios that we see such as trochlear dysplasia, patella alta, quadriceps angle, RTT to TG ratios on the MRI can tell us a lot about where that kneecap sits and the risk of potential future subluxations.

[Dr Drew Duerson]
And I can chime in too, Eric. I think this exam is a tricky one because when a patella dislocates, it's very painful and there's a large effusion that usually results. So, the patient comes in mostly with an extended knee, unable to flex, very uncomfortable due to the size of the effusion.

And often with this type of injury, we go back to the sprain. So, we see a pretty high level of sprain or tear of the medial patella femoral ligament or MPFL. And that's painful.

Often, there's a contusion injury. So, when the patella dislocates, it's often laterally. And when it's reduced back into its normal position, the patella and the femur will hit each other and cause some pretty significant contusions.

And often, it's not just a bony contusion, but you can, again, get an articular injury as well. So, this is a tricky exam because the patient is very uncomfortable, and you can't really do a whole lot. So, you have to rely on history a lot of times, which sometimes these things happen fast, and you maybe don't get the perfect history.

So unfortunately, in my practice, I often have to rely on imaging. And I'll go to point of care ultrasound as an example. I can look at the medial patella femoral ligament.

I can see if there's any tear. I can try to look at the patella and its articular cartilage. And then like Ben was saying, to measure things like the tibial tuberosity to trochlear groove distance, that's something that we could only do on MRI.

And we can get some ideas of trochlear dysplasia, but to really make the accurate measurements, we need an MRI. So, these are one of those injuries where you do your best with history, you try to do an exam, maybe use some tools like point of care ultrasound, but MRI can be a very, very handy tool as well.

[Benjamin Lee]
Yeah. And going off of that too, that those are a lot of things that we see early on in those patellar subluxations. When they come to us in rehab, typically those attributes and those things such as large effusion, lacking that knee flexion and being unable to bend the knee start to resolve, but they're still very present.

So as far as treatment goes, we want to get that swelling down, right? First, making sure that kids are icing at the end of every day, especially when they're on their feet all day at school, and then some load management and activity modification, making sure they're staying out of more stressful activities for that part of the body, such as running and jumping for a while in the early parts of rehab. And then building on top of the swelling, getting that range of motion back.

Like Drew was saying, it can be hard and almost sometimes fearful and scary for a kid to bend their knee again after dislocating their kneecap. And so, working through a very intentional and comprehensive flexibility program to get that knee bending again is paramount. We also want to work on strength in rehab.

That is a very important part, especially for that quadriceps muscle in the front of the thigh. The strength of that muscle can really help dictate how stable that kneecap can be in the future. I tell kids that this is often their body's natural kneecap brace and that the stronger that muscle is and the faster it can contract, the lower risk they have of potentially dislocating their kneecap.

And then as we work through rehab, we start integrating that strength into power and getting that back into activities such as jumping, landing, and twisting that initially may have caused that injury to begin with. So, building on those things and really kind of preventing and reducing the risk of a future dislocation is kind of the way we go through things in rehab for those patellar subluxations.

[Eric Leighton]
And one item I like to throw in, so whenever we're examining this, particularly out in the field, so if somebody, you know, on the court, on the field goes down, I'm going to do a field exam as an athletic trainer or even in clinic. When you do the apprehension exam, the patellar apprehension, so patients lying supine, you generally have the patella, you know, bracketed against your fingers and you're generally going to be moving the patella laterally. And that's, you know, if they flex and then suddenly contract the quadriceps and bring it back central, it's that apprehension sign.

But a key pearl about that is don't just push that sucker laterally; you're waiting for the response because you don't want to recreate that injury. So having your thumbs then on the outside as well as sort of a guardrail, we don't want to throw them into another subluxation or dislocation.

[Dr Drew Duerson]
Eric, tell me you've never done that before. 

[Eric Leighton]
What's that? Put them into it?

[Dr Drew Duerson]
Yeah, put them into a patellar dislocation. 

[Eric Leighton]
I haven't.

[Dr Drew Duerson]
Good. 

[Eric Leighton]
Always been really careful about that. So going back, I'm still on the knee, obviously.

Drew, meniscal injuries, man, we know these can sideline and just, you know, tank an entire season. What are the most common causes here? Where do we see the meniscal injuries happen?

[Dr Drew Duerson]
Dr. Drew Dixon Yeah, these can be broken up into categories too, I believe. These can be both acute from trauma and maybe more chronic from degeneration. I'd say in our population, we see the acute traumatic meniscal tears.

These are often a non-contact injury, but they can be contact as well. Really anything that causes a twisting mechanism to the knee. So, a foot planted, a sudden position change, a jump and a landing, really any type of sport that involves that type of movement.

So, basketball, soccer, volleyball, just to name a few are going to be the most common places we see these injuries happen. Tanner Iskra All right.

[Eric Leighton]
Ben, probably one of the biggest, the most famous injuries, the dreaded ACL. You know, you hear on sports broadcasts, you know, or you hear things, oh, it's a season-ending injury, the ACL. But of course, we could also be dealing with PCL, MCL, or LCL as well.

What's the typical approach once we get these to rehab?

[Benjamin Lee]
Dr. Ben Miller Yeah. Well, first off, Eric, as you know, ACL rehab is a long, long process. I was actually talking to a patient yesterday as we were working through rehab, and he was saying that one of his mentors and coaches, when he tore his ACL, said, man, it's a long process.

It's a painful process, but you will come out of it a better man. And from the patients that I've seen, you know, I couldn't agree more with what his coach had to say to him. To simplify rehab, I can kind of divide it up into three different stages, the early stage, the mid stage, and the late stages of rehab.

In the early stage, our main goal as PTs is to protect the operated structures, whether that be the repaired ligament itself, or the muscle or tendon where the ligament was grafted from, whether that be a hamstring tendon or quadriceps tendon, or a patellar bone tendon as well. We also want to reduce swelling in this early stage, similar to the early stages of a patellar dislocation. We make sure that kids are icing at the end of every day.

Consistently, they are provided ice machines and compression machines by their surgeons as well from our clinics. And then making sure that they're following weight bearing protocols, whether that be not weight bearing at all through the leg if they have a concurrent meniscal repair, or just having a certain percentage of weight bearing in the early stages of rehab. We also want to restore that range of motion.

It's critical to get that full knee extension or straightening back as soon as possible, and then eventually working into flexion as our protocol allows. And then in the early stages, trying to wake up and work on some early quadriceps strength can go a long way too. After surgery, something that we commonly see is called arthrogenic muscular inhibition, which is when we go in through a joint and we see that the muscle is a lot more inhibited after a knee surgery.

It's something we see in many knee surgeries, not even just ACLs as well. And so, one thing we do in rehab is use electrical stimulation to kind of wake up that muscle again. We'll take some big pads, slap it on the front of their thighs, and certain kids love it.

Certain kids really shy away from it but getting that muscle contracting early on is a big deal. Moving from the early stage into the mid-stage, we can build that strength more and more as it's safer to move and kind of exercise and strengthen the muscles around the knee, especially the quadriceps muscle that we just mentioned is super important to strengthen. Eventually, we will have our patients undergo strength testing, whether that be through handheld dynamometry at each of our clinics or having them travel out to Westerville where we have isokinetic dynamometry, where they'll have their legs strapped into a machine and they'll be kicking as hard as they can up and down just to measure the strength of their thigh muscles on their affected knee compared to their unaffected knee. Based on how that testing goes, the athlete will eventually be cleared to run and jump and move into the late stage of rehab. And this is where our functional rehab friends like Eric come in and kind of provide patients a new change of scenery.

They start doing more sport-specific activities like running, jumping, sprinting, and cutting and eventually have to pass return to sport testing, whether that be physical testing as well as psychological testing and receive surgeon clearance to return to sport. Once all those goals are met, they finally cross that long-anticipated bridge of getting back to their sport. But it's a long rehab, Eric.

It's an arduous process, but it's certainly a joy to walk through these patients through this long journey that they undergo.

[Eric Leighton]
Yeah. And as you mentioned, yeah, being a long one and a very tough one at first, but they do come out of there stronger and better. And one of the other things we do is in that mid-stage or sometimes during the transition from mid to late stage, we also get them fit up for their functional bracing.

So, they'll wear that functional ACL brace, which helps stabilize the whole joint, gives them a little confidence as well.

[Dr Drew Duerson]
I would just add too, this is, you know, probably the most difficult diagnosis that we have to make to our families. This is the one diagnosis that usually causes tears in the room. And, you know, I think with that, this is, you know, hard from a lot of different perspectives, not just physically, but mentally.

So, trying to prepare the patient before they even get to see Ben or Eric in rehab is very, very important to, you know, try to keep them as optimistic as possible because it is a long journey to get back. But if we can, you know, ensure them that, yes, we can get you back to the same level of play and get you back on the field or the court, participating in what you love to do, you know, is very, very important. And, you know, I think the biggest problem with ACL, it's so, you know, popular nowadays because, you know, it just happens, you know, so, so often is we do a fairly poor job in prevention.

And I know that could be a whole PediaCast in itself, but, you know, I did want to emphasize the importance of preventing these injuries as best we can because there's so many good preventative programs out there. They're just not utilized like they should be. And this really needs to be a focus of our, especially our female athletes early on in their careers, you know, in middle school, even maybe even earlier, getting our coaches on board with this idea where we can maybe spend some of the time in the off season where we do some of these preventative programs.

I think it could go a long way because they've been proven to work if we use them and use them the right way. Yeah.

[Benjamin Lee]
And to tag on to what Drew was saying, it's such a common injury, but it's so important to have a multidisciplinary process, right? Talked about some of the mental aspects of it early on. I mean, in rehab, we see it even in the late stages where it's like, man, am I ever going to get back to my sport?

Am I ever going to pass my strength testing again? And that's where collaborating with sports psychologists and behavioral health can go a long way. Just want to give a shout out to Dr. Heather Richard with our team, one of our sports psychologists here. She's done a great job with some of the patients that we've seen to help counsel them through that mental journey and the hurdles they have to overcome in their rehab. And then like Drew mentioned, the prevention or injury risk reduction process on the front end is so important. Our sports performance specialists or strength coaches at high schools just do a great job with working with our athletes to make sure that they have as much strength as possible, movement literacy, and just movement competency on the front end to kind of help reduce the risk of these injuries.

But really, I mean, it's such a multidisciplinary and collaborative process to both prevent and treat these injuries.

[Dr Mike Patrick]
You know, when you have a student athlete who has to be sidelined for quite a while and they're undergoing rehab and healing from their injury, how do you recommend that they stay connected with their team? I mean, are there still ways that they can be involved and feel like they're part of the effort without actually being on the playing field?

[Eric Leighton]
Yeah, you know what? A lot of times, oh, I'm sorry, Ben. A lot of times, we always encourage the kids to continue to work with the team, to go to practice, reminding them there's still some learning you can do.

As the coaches are running plays, as they're diagramming plays, you can still be learning and mentally walking through this or even helping out with the team. Obviously, the more functional they are, once we have them off of crutches and they can move around a bit, getting out there, finding them a slot with the coach. And I'll talk to the coaches and be like, hey, listen, let's find something that Timmy here can do, maybe as an assistant coach, kind of help out, keeps them connected to what they're doing and gives them, as you said, gives them purpose.

One thing we definitely were trained on a little bit in school, but as you mentioned, Ben, and Drew both, I mean, the mental health part of it, because it is such a long journey, we literally see kids go through the five stages of grief on these types of injuries.

[Benjamin Lee]
Yeah, and to add on to that, it just depends on what stage of rehab they're in, right? I've got a kid right now in the early stages and she is doing manager work for a basketball team. It stinks.

She had to miss her senior year. This is her last year, but she's helping coach up some of the younger girls in practice and is a part of the team, helping decorate the locker room for opening night a couple weeks ago. So that goes a long way.

And then as they clear certain stages and become safe to do certain things, such as getting back in the weight room and working out, right, making sure that we have very clear restrictions can go a long way. Like, hey, make sure that you can do everything, but your knee can't bend past 90. This is what that looks like.

Okay, cool. I can do that, right? That can just go a long way in terms of, like Eric said, helping their mental health, but also their physical health as well.

And just giving them that piece of participation and strengthening outside of rehab can go a long way.

[Eric Leighton]
Ben, I got one more for you here. A couple of the biggest injuries that we'll see, some of the most common tendon, tenderness injuries are going to be that extensor mechanism we mentioned earlier. So, the quad through the patella and also the hamstrings.

So where do we tend to see these the most?

[Benjamin Lee]
Yeah, so for patellar tendinopathies, this is again that patellar tendon underneath that kneecap. We tend to see it more in adult populations than pediatrics. However, we do see some in more of our skeletal mature adolescents, say maybe like more the junior, senior year of high school, or even some of our college-aged athletes.

These are typically more common in sports with a higher volume of jumping and landing. Think about how much your knee has to bend and that patellar tendon has to undergo stress with those sports, such as volleyball, or basketball, or gymnastics. For hamstring tendinopathies, that's typically at the back of the knee, or the out back on the outside or back on the inside of the knee, where that kind of stringy part of the either the medial or lateral hamstrings attaches to the posterior knee.

These are more common in athletes that are involved with a higher volume of running, such as cross country or soccer athletes, where that knee is often extended, and that hamstring tendon has to undergo a more of a tensile force continuously. As far as rehab goes for these athletes, it's more about, again, activity modification and strengthening of the appropriate muscles. What I often tell kids with both these tendinopathies, as well as with growth plate injuries that Drew was talking about earlier, is activity modification comes down to two different things.

One would be increasing their capacity, so making sure that their tendon or their muscle is able to do more, as well as decreasing their activity for a temporary period of time. If we think of it like a cup and water filling the cup, the cup is how much you can do, and the water is how much you're asking your body to do. So, we can do two things in rehab.

One, we can temporarily reduce how much water goes in the cup. And the second thing we can do is make a bigger cup so that they're able to do more in the future and have a reduced risk of having these types of injuries or pain again.

[Eric Leighton]
Very good. So, Drew, I'm going to come to you for this last one. We have talked about a lot of things around the knee, lots of various types of injuries and different ways we have to approach it.

We know there's a lot of injuries to consider, but your experience, clinical experience, what are some of the biggest pearls, in your opinion, when it comes to those exams, diagnosis, and then the rehab?

[Dr Drew Duerson]
So, I think first, history is very important, and you hear that often, but in kids, with a knee injury, it's specifically important for us to dive in and take a very good history. We need to be able to categorize these injuries into, is this an acute traumatic thing, or is this more of a subacute injury that's just starting or is this more of a chronic intermittent type of pain the patient's having, and that really helps us focus our physical exam. So taking a good history is always vital, and then from there, I would say one pearl, and that we haven't really touched on a whole lot, and this is very specific to pediatrics, is being able to examine a knee and know if there's a knee effusion or not, and you would think that would be simple, but for a lot of us, even me today, takes some practice, and there's some variables there, body habitus and other things that you have to deal with, but being able to walk into a room and look at a knee, touch a knee, and be able to feel or see a knee effusion is key, because for a kid with a swollen joint, that's not normal. If it's my knee that's a little bit swollen as I get older, that's probably some osteoarthritis that's developing, maybe not as big of a deal, but if you've got a kid in front of you that's got a knee effusion, you need to figure out why it's there. If it's acute traumatic thing, there's a pretty short list of possibilities.

It's one of the things we've talked about, patellar dislocation, an ACL injury, PCL injury, meniscal injury, could it be a bony injury, a fracture, or an osteochondral injury. So, those are all things that often need some type of surgical treatment, so you don't want to miss those things. If it's more of the chronic intermittent knee that's swollen and you determine that there is a true effusion, that may be something that I think sees us more than we see it, arthritis.

So, kids can get arthritis, and we don't want to miss that because that's going to involve more of a systemic treatment and need to potentially be referred to the right physician. So, I think really being able to determine if there's a knee effusion is key, and then sometimes it's hard. So, you know, I've thrown a plug in a few times already, but point of care ultrasound, you could make that diagnosis in seconds with an ultrasound in your hand.

So, you know, not being afraid to use that as a tool, and then I guess the last little pearl is, you know, especially chronic knee pain because we see this very, very often in clinic, and this can lead to a lot of inactivity. So, you don't want to neglect that pain. You want to be able to find a good diagnosis and get them, you know, to see Ben or Eric or whoever it may be and really emphasize the importance of therapy because if we can rehabilitate that knee, we can get these young kids especially on the road to recovery so they can get back to being active again.

And we all know, you know, the outcome of inactivity in our young patients. So, those would just be a few of the pearls that I feel are important.

[Eric Leighton]
All right. Thank you, guys. I think we've definitely covered the gamut of knee injuries.

Obviously, there's always more we can go into and more study and more reading, but I think it was a pretty good discussion. Mike?

[Dr Mike Patrick]
Yeah, I thought it was really terrific, and I learned a lot. Drew, if I could ask you, are there courses where physicians, and in particular, I'm thinking primary care physicians, can learn how to do point-of-care ultrasound?

[Dr Drew Duerson]
Yes, there is. And we actually just had a conference in November here that we do annually where we do a hands-on musculoskeletal ultrasound workshop, and we see physicians of all sorts, athletic trainers, physical therapists, and that would be a great place for local people here in Columbus, Ohio. But not just here, you will find courses all over the country that you could take advantage of.

And then I would argue a lot of this can be self-taught. You can either rent or purchase a fairly priced handheld ultrasound nowadays, watch videos online, scan yourself, significant others, you know, eventually patients. And once you see enough normal sonoanatomy, you know, specifically a knee effusion, it's very hard to miss.

So yes, I think this is a, you know, one of those ways that really anybody could use an ultrasound as a tool in their clinic to help them.

[Dr Mike Patrick]
Yeah, and that would also help, like, is this something I need to refer to sports medicine, or is this something that is likely just with rest and ice and elevation and, you know, just going to get better on its own?

[Dr Drew Duerson]
I would argue if you were suspecting or have been able to diagnose a knee effusion, that is one of those key things that you don't want to overlook. And yes, probably requires some type of referral, or at least a further workup by the primary care provider to, again, figure out why that knee effusions there. And a lot of the other injuries that we've talked about today that can result in a knee effusion, like the meniscal tear, the ACL tear, yes, we would be more than happy to see those in our sports medicine clinics.

[Dr Mike Patrick]
Great. And we are going to put a link to sports medicine at Nationwide Children's Hospital in the show notes. And also, to physical therapy, the sports and orthopedic folks in physical therapy, we'll put a link to that program as well.

And then we will have more resources for you, some really aimed at pediatric providers and then others for patient and family education. So be sure to check out the show notes over at pediacastcme.org. This is episode 102, and you'll find all those resources there.

So once again, Benjamin Lee with physical therapy and Dr. Drew Duerson with sports medicine. Thank you both so much for stopping by today.

[Dr Drew Duerson]
Thank you for having me today, Mike. Thanks, Mike. As always, this was great.

Appreciate it.

[Dr Mike Patrick]
Yeah, really, really appreciate you guys taking time out to do this. And then, of course, thanks again to Eric Leighton. He's a certified athletic trainer and leads the functional rehabilitation program at Nationwide Children's Hospital.

And he is our point guy for all things sports medicine on PediaCast and PediaCast CME. So, Eric, thank you also for all your hard work today. Thank you too, Dr. Mike.

[Eric Leighton]
I really appreciate the opportunity to come to the studio and hang out with you guys.

[Dr Mike Patrick]
Perfect. Okay, let me get started. So, we are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it.

Really do appreciate that. Also, thanks to our guests this week, Benjamin Lee with physical therapy and Dr. Drew Duerson with sports medicine, both at Nationwide Children's Hospital. And, of course, again, thanks to our guest host this week.

He did a great job leading the conversation, Eric Leighton. He's a certified athletic trainer at Nationwide Children's. Don't forget, you can find us wherever podcasts are found.

We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, YouTube, and most other podcast apps for iOS and Android. Our landing site is PediaCastCME.org. You'll find our entire archive of past programs there, along with our show notes, our CME information, the terms of use agreement, and our handy contact page if you would like to suggest a future topic for the program.

Reviews are also helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show, and we love connecting with you on social media. You'll find us on Facebook, Instagram threads, LinkedIn, and Twitter.

Simply search for PediaCast. So, you've listened to the podcast. Now, be sure to claim your free Category 1 Continuing Medical Education credit.

Really easy to do. Just head over to the show notes for this episode at PediaCastCME.org. You'll find a link to the post-test in the show notes.

Follow that link to Cloud CME. Click on the Materials tab taken past the post-test, and the Category 1 credit is yours. Super easy, right?

And, again, we offer credit to physicians, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists, as long as the content of this episode matches your scope of practice. Complete details are available at PediaCastCME.org. And then we do have a couple of other podcasts to tell you about.

First, of course, PediaCast. That is our plain PediaCast without the CME. It's an evidence-based podcast for moms and dads.

Lots of pediatricians and other medical providers also tune in as we cover pediatric news, answer listener questions, and interview pediatric and parenting experts. Shows are available at the landing site for that program, PediaCast.org. Also available wherever podcasts are found.

Simply search for PediaCast. And then we are launching a new podcast in January, so next month, called FAMEcast. Now, Fame is the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine.

So, it's really all about making academic – well, the mission of Fame is to support academic medical professionals in terms of work-life harmony, their jobs. And we are also launching a brand-new podcast next year, actually in January of 2025. It's called FAMEcast.

Fame is the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine. And this is going to be a podcast for academic medical professionals. And we're really going to be thinking about things like mentoring and coaching and teaching, especially in busy clinical environments.

We'll talk about promotion and tenure and really just all things faculty development. Work-life harmony, that's another important one. So, look for that.

We're going to be launching January 2025. You'll find the show over at FAMEcast.org. And of course, it'll also be available wherever podcasts are found.

Again, that is launching in 2025. Thanks again for stopping by. And until next time, because we do have one more episode for you before 2024 ends.

And until then, this is Dr. Mike saying, stay informed, keep it evidence-based, and take care of those kids. So long, everybody.

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