Friday, April 3, 2015
16 Year Old Male with Knee Pain
This is a 16 year old male with medial knee pain, swelling and loss of range of motion. Insidious onset. Started hurting after beginning basketball practice. Can walk FWB but this seems to cause more swelling and discomfort. Rest and decreased WB help. View the AP image and each member of the class note one thing about the image. You are welcome to make a guess as to what you think the problem is. Uses ABCs to make comments regarding this image. You should not need to make the same comments as long as everyone sticks to only one comment about the image.
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Initially this image looked normal to me, displaying no significant abnormalities. I had to spend a lot of time zooming in and looking at the bones and examining each landmark carefully. There is a white jagged line on the medial portion of the femur. The line is whiter than the rest of the bone indicating increased density. I believe this could be indicative of a healing fracture. The line is white and does not contain black which would be air meaning that the bone is not separated and the fracture is either healing or a stress fracture. As this is not an acute injury I do not believe this could be a cause of the patients current pain.
ReplyDeleteThis is a tough one because the image looks normal. I tried to compare this image to a "normal" image of the knee. The only thing I can come up with is it looks, to me, like there is a loose body in the medial joint space near the medial femoral condyle. My guess (based on if my guess about the image is correct, age, sex, and activity level) that his pathology is osteochondritis dissecans.
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ReplyDeleteWhen looking at this image it appears fairly normal as my classmates have stated above. I also notice the increase in uptake along the superior and medial aspect of the R tibia. This may be indicative of a previous fracture or contusion to the knee that is healing. I still believe that overall the image is normal however, I think another angle or view of the image may show something that "I and we" may be missing. One view of any image is really no view because there should always be multiple views taken of an image. If the image is normal I think that the patient may have other musculoskeletal deficits that are attributing to their pain on the medial side of the knee.
ReplyDeleteHonestly, my best educated guess is the presence of osteochondritis dissecans, due to the presence of a dark spot near the articular cartilage of the medial femoral condyle. However, because Katie took my OCD Lesion answer ;) , I would like to predict that there is some sort of osteophyte in the patient’s knee, which could explain the patient’s symptoms and the insidious onset of the pathology.
ReplyDeleteIt appears to me that the patella may be sitting slightly medial, which could explain some of the medial knee pain. I noticed the areas that the others pointed out and agree with them as well. Matt's musculoskeletal diagnosis lines up closely with my observation as muscular imbalances could cause increased compression on the medial side causing inflammation and pain with walking. Lucky for this patient there are no obvious bony faults, but if definitely gives a good challenge to whoever is interpreting the image.
ReplyDeleteMaybe this is looking too far into this x-ray, but I feel this kid may have an externally rotated patella. It looks as if the inferior pole of the patella is more lateral compared to the superior pole. This mal-alignment may be causing abnormal stresses on the patellar tendon during weight bearing.
ReplyDeleteI agree with my classmates in the fact that this is tricky to pick out the deviations from "normal" since there is no obvious deformity. I feel like there is a component of tibial internal rotation. The posterior intercondylar tubercle of the tibia seems to be more lateral than the anterior tubercle.
ReplyDeleteThe femur bone is more radiolucent than I would have expected. Normally I would expect to see a strong, bright white femur bone that is radiodense, especially in a 16-year old who plays basketball.
ReplyDeleteAs many others have said, it is difficult to find anything glaringly “wrong” with this radiograph. One thing that I did notice is the relatively dark (radiolucent) spot located at or just posterior to the inferior pole of the patella. It makes me question whether or not the density of the bone in this area is normal for such a young, active patient.
ReplyDeleteWell, to not repeat something anyone else has said, my new observation would be that the alignment of the knee looks a little shifted. It seems like there is more tibia over on the lateral side that the femur is not in contact with than on the medial.
ReplyDeleteI noticed that Katie McClellan posted what I was thinking would be the issue seeing that there is either a bone spur or something floating on the medial femoral condyle which could indicate osteochondritis dissecans......since that is already taken. Since there seems to not be much "wrong" with this radiograph the patient could have an issue with his medial meniscus.
ReplyDeleteI believe this is a lesion to the medial femoral condylar articular surface, possibly OCD, with osteophytes at the medial joint line. I also suspect patella alta causing the discomfort secondary to faulty patellofemoral mechanics.
ReplyDeleteIn conjunction with Susanne's comment and viewing the alignment of the tibia to the femur (as well as the young man's thigh and calf musculature alignment), I believe this young man could have slight genu varus or bow-leggedness. But as Matt also commented, "one view is no view" - so a lateral x-ray could help us to determine if there is any osseous pathology. Since I do not see any bony deformity, my guess as to this young man's problem is: a soft tissue deformity such as MCL sprain, but that could be ruled in or out by our PT special tests and/or an MRI.
ReplyDeleteSoft tissue observation: Normal contour of quadriceps muscle indicating a lack of atrophy, and confirmed by lack of patellar baja (normal frontal plane positioning of patella).
ReplyDeleteThe fibula appears to be neither fractured nor displaced indicating proper function of the proximal tibiofubular joint. If the patient is suffering from osteochondritis desicans, I would inquire as to if they have noticed any clicking, locking or giving way of the knee joint.
ReplyDeleteB of my ABCS: hope this is all you were wanting rob! There is some Lucency of the medial femoral condyle. This along with bone pain and swelling in a young male could be an osteosarcoma. The distal femur is the most common site
ReplyDeleteAs many others have pointed out, I agree that this image isn’t appearing extremely abnormal or problematic right off hand. With Susanne and Roxi, I agree that the alignment looks “shifted” and there also appears to be a muscular imbalance between the vastus lateralis and medialis. With these findings and the described symptoms I would assess ligamentous integrity, involvement of bursa, and also muscle strength (fundamentally squat, SL step down, etc.) to see if knee valgus or varus is present.
ReplyDeleteGreat comments so far everyone. You dont all have to try to find something wrong. Feel free to post what you feel is normal. If there is a pathology I will let you know with a follow up post after everyone has added comments.
ReplyDeleteI agree with everyone about a possible fracture (or healed fracture) at the medial femoral condyle. It appears to me like others that there is some loss of shape of the medial femoral condyle, leading us to believe there is an OCD lesion. I think Erin and Susanne make good points about muscle imbalance. I will disagree with Katie that the patient is in genu varus, to me it appears he is sitting in more genu valgus. Based of bone alignment and what appears to be a slightly decreased joint space laterally and slightly increased medially. I do however agree with her with expecting MCL involvement. The pain and swelling in WB would make my first thought OCD lesion, my second thought is MCL sprain or tear. Even though there is no real detail about MOI, other than beginning basketball practice. I think basketball could definitely cause an MCL tear.
ReplyDeleteI agree with many of my classmates on the possible pathologies from this image. I do believe that further testing needs to be done to confirm any one pathology. In regard to what is "normal", I think there is good joint space between the femur and tibia indicating no swelling or joint effusion at the time of the X-ray.
ReplyDeleteI noticed that you can clearly see the fused epiphyseal plates (growth lines), consistent with the patient's age. I also agree with my classmates who report that the patella appears to be more medial, so this patient may be experiencing improper patellofemoral mechanics.
ReplyDeleteI agree that the patella seems to be more medial than "normal", but I wonder about the alignment of the femur as a whole, as there seems to be decreased space between the lateral femoral condyle and the intercondylar eminence of the tibia.
ReplyDeleteJoining the discussion at this point makes it difficult to point out anything new or unique. Looking at this radiograph using the ABC'S search pattern, many classmates have pointed out the alignment abnormalities of the tibia and patella, as well as the difference in the uptake/bony contour/joint space of the distal femur when you compare medial to lateral. I would definitely agree with these findings. In regards to what is causing this, I would also agree that more subjective information/further testing is needed to confirm any one cause. Initially, Paige's post about an osteosarcoma caught my attention, but further research into radiographs of these show much more bony abnormality than what is present here. From a PT standpoint, I mostly agree with Erin in that I would assess soft tissue and muscular strength integrity and attempt to correct alignment, after other bony lesions (stress fracture, OCD, osteosarcoma, etc.) are ruled out.
ReplyDeleteI have stared at this radiograph for so long! I was then looking at quite a number of normal AP knee x-rays and was trying to make comparisons. Nothing seems to be glaringly obvious, so I would perhaps perform a musculoskeletal exam and further testing in person, like a good majority of the class has stated. I would point out that you can clearly see his epiphyseal plates. In males, I believe that they tend to close around 15-17 years of age, which is right around how old this kid is. So I would potentially look into that. I would like to know what his true diagnosis is!
ReplyDeleteLike most of the class, I believe the radiography looks normal for a 17 year old boy. Reading his symptoms my first through was a possible MCL sprain or rupture (which obviously wouldn't show on a standard radiography). When I look closely at where the attachment site of the MCL would be on the femur it does seem like the border is less defined then the rest of the boarder of the bone (which may indicate inflammation.. possibly?) I believe that in this case I would go with what other of my colleagues decided to do and would do a full muscularskeletal exam, with close attention paid to the medial collateral ligament.
ReplyDeletecorrection: 16 year old
DeleteAfter reading the patient's subjective history, without looking at the x-ray, my initial though would be MCL sprain or medial meniscal injury. Without any specific mechanism of injury - I feel that an MCL sprain is not likely. I would want a more in-depth history: Has he ever hurt his knee in the past? What was he doing before beginning to playing basketball/previous activity level (i.e. was he deconditioned?)? etc. Along with some of my fellow classmates, I feel that a full musculoskeletal examination is indicated. After viewing the x-ray, I agree with Vince that there appears to be increased joint space on the medial aspect and decreased joint space on the lateral aspect, indicating possible genu valgus and likely hip weakness allowing the patient to fall into adduction when jumping, walking, running, etc. I would do a complete musculoskeletal examination and I believe that I would likely find weak gluteus musculature. I would say that an MRI is the next step in process and would identify any soft tissue abnormalities that could be causing his medial knee pain.
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ReplyDeleteI am curious what his patellar tracking looks like with open and closed chain kinematics. If the patella is sitting abnormally (ABCs), that could explain the pain with WB and the soft tissue differences previously noted. Also if rest and decreased WB relieve pain the patient is most likely not moving the extremity during these times keeping the patella in one place. Just a thought of something that can drive your examination based off of imaging.
ReplyDeleteSincerely, Cody Glick
By looking at the radiograph you can see that the epiphyseal plates across the proximal tibia are fused, however, they are still evident. At age 16 this is an appropriate finding on a radiograph. Other normal findings: the inferior pole of the patella does not cross the joint space, the medial and lateral joint spaces appear to be of equal height, the long axis of the tibia and femur appear to be aligned. However, when looking at the long axis of the tibia and femur it also appears that there may be a slight rotational mal-alignment.
ReplyDelete- Lauren Waits
This is a 16year old male that appears that the epiphyseal plates are closed. He could still be experiencing growth changes causing pain in FWB. It also appears that the superior portion of the patella is tilted laterally that could cause issues with compression of the patella or patellar tracking.
ReplyDeleteUsing the ABCs, I notice that the patient's general bone density looks normal. Barring the aforementioned possible site of healing or old stress fracture on the medial portion of the femur, the patient's radiograph exhibits sufficient contrast within each bone (tibia, femur and fibula), specifically between the denser cortical shell and the cancellous center, which is relatively less dense. This would suggest the patient has normal mineral content of his bones.
ReplyDeleteWith alignment, I don't notice any abnormalities in comparison to other x-rays I looked at, but a secondary view and imaging of the other leg is required for full assessment. Bone density appears mostly normal with the exception of abnormality on the ends of the medial femoral condyle and tibial plateau. Cartilage space appears normal as well as soft tissue. Besides the possible OCD lesion, The only abnormality I see is the osteophyte formation at the ends of the Medial femoral condyle and medial tibial plateau (they should be straight and radiolucent, not pointy and darkened).
ReplyDeleteFrom the "C" portion of the ABC's, the cartilage space in this radiograph appears to be very good and symmetrical. There is no collapse of either medial or lateral compartments. As some of my classmates have pointed out, there may be a small shift in alignment in the transverse plane, however the alignment of overall tibia to femur looks to be typical. Considering the joint space is equal, I don't believe there are any major malignments, however the biomechanics may still be abnormal and contribute to the overall pathology.
ReplyDeleteAfter reading the subjective part of the patient's history, it would lead one to believe there could be a stress fracture or damage to the bone that would be causing this problem. However, after looking at the x-ray and reading the extensive comments of my classmates, I think we can all agree there is nothing that jumps out and grabs you as far as bone pathology goes. This young athlete clearly has good alignment, bone density, and joint spacing in this knee. I'd be more interested in how the soft tissues surrounding this knee are operating and potentially creating pain.
ReplyDeleteGiven this patient’s medial knee pain and swelling that is worsened by WB, the first thoughts that come to mind after looking at the radiograph are possible osteochondral defect/lesion on medial femoral condyle. The radiograph seems to have an area of decreased radiodensity (i.e. more radiolucent) on distal medial femoral condyle. This could be indicative of area of softened/defective articular cartilage. Such a lesion would present as more radiolucent than surrounding articular cartilage and cortical bone because it would no longer possess the tissue integrity and density, and would contain inflammatory substances from the body’s compensatory healing mechanisms.
ReplyDeleteAfter reading discussions thus far and looking at this radiograph, I agree with most of my classmates’ comments using the ABC’s search pattern. Regarding the image, many comments have been made regarding alignment abnormalities of the patellofemoral and tibiafemoral joints, and joint space differences when comparing the femoral condyles medial to lateral. I definitely agree with most classmates that these findings further warrant gathering more subjective information and musculoskeletal examination (including MMT of hip and knee, functional DL and SL squatting, SLS, gait analysis, etc.)
ReplyDeleteIn regards to what the problem is – Although I agree with some of my classmates, I’m going to approach this from a different angle. Based off the subjective information given, the patient’s age, sport, etc. and objective findings on the radiograph, I would also want to confirm the possibility of an ACL tear. Reason being – the ACL’s attachment to the medial, anterior aspect of the medial tibial plateau and superiorly, laterally, and posteriorly on the lateral femoral condyle. As the ACL is the primary stabilizer of the knee, and secondary to various joint abnormalities in alignment on this image – would it be safe to say he could possibly have torn or damaged his ACL??? Could this explain his malalignment and “shift?” The medial knee pain could be due to the ACL’s attachment or the ‘happy triad’ with some MCL or medial meniscal involvement. But, swelling, insidious onset, loss of ROM, better with decreased WB and rest as FWB increases swelling and discomfort, and it occurred during basketball – I think an ACL pathology could be very plausible. But, like I said, just a different perspective to give everyone.
Based off of the radiograph, subjective, and using the ABC method. The alignment and bone density appear to be normal overall. The joint spacing medially and laterally is equal with no major stand out issues. It does seem like the there may be a lateral patellar tilt which some of my other classmates have already mentioned and could be caused by patellar tracking issue. I have to wonder if it is caused by laxity of the lateral patellar retinaculum or if the patient has muscle imbalances leading to the knee pain. I believe further examination is needed to determine the actual diagnosis.
ReplyDeleteOverall the findings of the X-ray appear to be pretty insignificant. The major findings that I see are medial patellar alignment with patella alta. I also have to agree with many of my class mates that there appears to be some sort of radiolucent object along the medial femoral condyle. Another thing that I have to question is the contours of the medial tibial/femoral condyles along the medial joint line. They appear to be more pointed and don't have as smooth of contours as many X-rays that I have seen. While this would be very surprising due to the patient's age, they almost look like osteophytes. From a PT's perspective these X-rays were definitely indicated due to the patients subjective history and age. However, I have to agree with Todd that pending all osseous deformities being ruled out, this patient would definitely benefit from PT in order to improve knee biomechanics with ADL's including running and jumping activities for return to basketball with decreased pain.
ReplyDeleteThis radiograph looks again like most other classmates have stated, pretty normal. The epiphyseal plates have completely fused and growth lines still present. I would be curious to see what this patient's Q angle is, which could be predisposing him to inadequate patellar tracking and resulting in instability.
ReplyDeleteI initially agree with Susanne's observation that I thought the knee looked a little "shifted", however it's hard to say for sure without a comparison. If the other knee presents similarly, I'd have to rule that out. Like many other people, I did notice the little spot by the medial femoral condyle. As MCL tear has been said several time's, I'm going to take a leap and take it a little further. Could it possibly be MCL avulsion from the medial femoral condyle? The lesion could be part of the condyle that was torn away, or possibly due to incomplete/incorrect healing.
ReplyDeleteSince the AB and C appear fairly normal, I focused on the soft tissue aspect and will suggest that the patient has traumatic bursitis. It is the least common form of bursitis, but it is typically seen in athletes due to repetitive rubbing of an extremity against a hard surface or from too much bending of the joint. I reached this conclusion based on the history: insidious onset, nothing obviously wrong in the x-ray, beginning basketball practice (lots of bending the knees during drills!), and increased inflammation and pain with activity.
ReplyDelete-Aimee Rieck
No concerns with bone density aside from floating osteochondral fragment on inferior medial femoral condyle and radiolucent area on medial femoral condyle. I thought about a possible ACL avulsion fracture but the osteochondral fragment sits right on the articular surface of the femur (a common site for osteochondritis desicans lesions that occur in children). The bony alignment and joint spacing looks good except for medial patellar displacement and possible patellar alta. I would recommend lateral view for insall-salvati ratio and MRI for possible soft tissue involvement. I would also be interested in patellar tracking mechanics.
ReplyDeleteWith the medially shifted patella, I would want to see the alignment of the hip and ankle to see if they are aligned normally or not. Also, possible musculoskeletal imbalances may have something to with the increase in pain with activity.
ReplyDeleteNice comments from everyone.
ReplyDeleteSome of what you describe are just simply normal findings. Slight valgus, patella alta vs baja, normal joint spaces, etc...
Some have described good cortical bone and normal looking trabecular bone.
Some of you were right that this patient indeed had a OCD on the medial femoral condyle which can be seen upon close inspection. It may be tricky to see as it looks like the back side of the condyle is superimposed right above the OCD making it easy to miss. Good comments from all on this first image!