pain in bilateral knees
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SUBJECTIVE DATA:
CC: “Complains of dull pain in both of his knees”
HPI: The 15-year-old Caucasian male complains of dull pain in bilateral knees. Complains of catching under unilateral or both knees. Onset gradual but increasing over time, especially in last two weeks. Dull knee pain and catching sensation behind the right knee cap. Rarely, notices the clicking in the left knee but continues to have less pain. Pain is worse with exercise and activity. Pain eases with rest, elevation and ice. Patient rates the right knee at 8/10 and left knee 6/10
PMI: Tonsillectomy at 5-year-old, Flu vaccination 2019 season, HPV immunization completed 2019, Tetanus 2019, hospitalizations
CURRENT MEDICATIONS: None
SH: RR is a middle school student at Austin Middle School. He plays football and basketball with the school. He is a nonsmoker and his household members are nonsmoking. He does not use alcohol and his father drinks 1-2 drinks/monthly and his mother does not drink. He lives in the house with both his parents. He makes good grades.
ROS
GENERAL: no weight loss, no chills, no fever, no fatigue.
CV: Negative for palpitations or flutters, negative for hypertension. No edema noted to bilateral upper extremities. No edema to lower extremities.
GI: No nausea/ vomiting no diarrhea, no stomach pain.
PULMONARY: Denies cough, shortness of breath or labored breath.
MUSCULOSKELETAL: Normal gait, ambulates without assistance or limb.
NEUROLOGICAL: No headaches, dizziness, syncope, paralysis, ataxia, and denies numbness and tingling in the extremities. Denies seizures. Denies trauma.
PSYCHIATRIC: No depression or anxiety
OBJECTIVE DATA:
VITALS: BP 120/68, P 86, RR 18, O2% 95%, 5’8”, 140#, BMI 21.3
GENERAL: Patient is a well-nourished 15-year-old Caucasian male. He is pleasant and cooperative. Complains of dull pain to knees. Right>left knee has catching sensation
CV: Heart sounds auscultated S1 and S2, no S3, no murmurs, no gallops noted.
GI: Flat abdomen, Bowel sounds normoactive in all 4 quadrants. No masses palpated.
PULMONARY: Chest symmetrical, unlabored breathing, Clear lung sounds in all fields, Percussion tympanic in all fields.
MUSCULOSKELETAL: Abnormal gait with limp favoring the right. Ambulates without assistance. No neck or back pain. Full ROM. Symmetrical bilateral upper extremities, no joint edema of pain. Full ROM. Full strength bilateral 5/5. Bilateral hip flexion 90 without pain, good strength 5/5. Right knee appears to have +1 edema to lateral aspect of knee and no bruising. Right knee is tender with palpation at the popliteal and tibiofemoral joint. Right knee is negative for the McMurray test. Negative Thessaly test to right knee. Right knee is positive at the Q angle 15 with clicking. Negative leg strength 4/5. Negative Thessaly’s test. Pain is passive and controlled range of motion. The left knee has no edema noted. Left knee has full ROM with pain, negative McMurray’s test, negative Thessaly test. Left knee Q angle at 15 degrees with clicking in knee. The left knee strength is 5/5. Bilateral ankle is symmetrical. Right ankle ROM intact, flexion 20 degrees and extension 45 degrees, strength 5/5. Left ankle ROM intact, flexion 20 degrees and extension 45 degrees, strength 5/5.
NEURO: Bilateral brachioradialis reflexes 2+ expected, bilateral triceps reflex 2+ expected, bilateral patellar reflexes 2+ expected, bilateral Achilles reflex 2+ expected. No clonus noted bilaterally.
DIAGNOSTIC RESULTS: 4-view x-ray of the bilateral knee, MRI of the bilateral knee without contrast as indicated below.
ASSESSMENT:
Patellar tendinopathy “jumper’s knee”-Overuse and overload to the patellar tendon. Gradual onset of pain and then becoming intolerable. Patient’s complain of dull aching pain with clicking or popping of joint (Dains, Baumann, & Schneibel, 2019, p. 21). A goniometer is used to measure the center of the patella to anterior superior iliac spike, the center of patella to tibial tubercle angle > 10 degrees in males and 15 degrees in females indicate tendinopathy (Dains, Baumann, & Schneibel, 2019, p. 21).
Osgood-Schlatter disease is an overuse injury and traction apophysis (Patel & Villalobos, 2017, p. 194). This disease is seen mostly in adolescent males in the Tanner stage of 2 or 3. Rapid growth and increased physical activity predispose the development of the condition. Localized tenderness and pain with resisted knee extension are an indicator of the disease. 4 view x-rays of the knee are used to diagnose. In an x-ray an ossicle may show in the fragmentation of the tibial tubercle in the patellar tendon.
Juvenile Osteochondritis Dissecans-Delamination and localized necrosis of the subchondral bone with or without the involvement of the overlying articular cartilage (Patel & Villalobos, 2017, p. 194). Repetitive microtrauma and local bone vascular insufficiency may be the cause. The lesion can be open or closed
