Children Are Not Mini Adults: Rethinking Sudden Anterior Knee Pain in the Skeletally Immature Athlete
MSKMag OutLoudShow Notes
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A 12-year-old soccer player lands in knee flexion from a jump and develops sudden left-sided anterior knee pain. He cannot continue playing, is reluctant to flex the knee, and describes giving way on weight-bearing. He cannot perform a straight leg raise (SLR) or adequately contract quadriceps because of pain and has an effusion. Plain radiographs in the emergency department are reported normal, and he is discharged without walking aids or follow-up. He presented for physiotherapy assessment. A story like this in a growing child should set alarm bells ringing. A normal X-ray does not mean ‘nothing to worry about’. Unless you know your paediatric anatomy and pathology, you may not appreciate that the tissue that fails under load depends entirely on skeletal maturity. Why adult reasoning isn’t enough here Adult MSK expertise remains highly relevant to paediatric practice; clinical reasoning, exercise prescription, and progressive loading principles still apply. But applying adult diagnoses and management without considering paediatric skeletal anatomy, growth, and pathology can lead to incorrect diagnosis and inappropriate loading. Same location, same mechanism, same sporting load - but a growing skeleton can fail completely differently to a mature one. The growing knee isn’t just a scaled-down adult knee It’s tempting to think of paediatric anatomy as ‘adult anatomy, scaled down’. It isn’t. A growing knee has structural features not present in the adult, and each changes how load, injury, and imaging must be interpreted. Every bone has its own ossification timeline, opening a ‘window’ for paediatric-specific pathologies that varies by site, sex, and individual. Depending on his maturation status, our athlete likely has a partially cartilaginous, still-ossifying patella with an active distal patella apophysis. In an adult, the patellar tendon attaches directly to cortical bone; in a child, it attaches to the apophysis which is structurally weaker than mature bone, and most vulnerable during rapid growth [1]. The patella and its distal apophysis don’t fully fuse until late adolescence. Once the physis closes, injury patterns revert to adult ones. Knowing where a child sits on this timeline is central to getting the diagnosis right. Are all 12-year-olds the same?
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It always struck me as bizarre that sports medicine and musculoskeletal specialties deal with pain and dysfunction from head to toe in the human body, yet offer little health literacy or inclusion of the pelvic floor. Traditionally considered taboo and someone else’s remit, men and women with issues affecting the pelvic floor have largely suffered in silence. Thankfully, change is afoot, and healthcare is finally evolving. There is much more awareness, inclusion, and understanding of this unique body area and the role that it plays. For anyone playing catch up, the pelvic floor is a group of muscles spanning the base of the pelvic outlet in layers. While both men and women have a pelvic floor, the pelvic outlet is wider in females than in males and it also contains an extra orifice – the vagina [1]. That’s right, we went there. We said the ‘V’ word. Because just like vulva, or vestibule, the vagina is simply an anatomical term. It needn’t be embarrassing or taboo. Some of you will be long enough in the tooth to remember when the word ‘breast’ was taboo. However, with healthcare campaigns for breast cancer and breastfeeding, this term became an anatomical norm. We need to do the same for the pelvic floor and its related anatomy and physiology. What does the pelvic floor do? In both men and women, the pelvic floor serves to control the bladder and bowel (maintain continence), empty the bladder and bowel (voiding and defecation) and support sexual function (arousal and climax). In women, the pelvic floor also plays an important role in pelvic organ support. Remember that extra orifice I mentioned earlier…well this area is high risk for connective tissue laxity and defects meaning that the pelvic organs (bladder, uterus, rectum) can descend into the vaginal cavity causing symptoms of heaviness, pressure and a sensation of ‘something in the vagina’. What are the signs and symptoms of pelvic floor dysfunction? If the pelvic floor is not doing its job, any of its roles can become compromised. This may manifest in leaking from the bladder or bowel, inability to fully empty the bladder or bowel, pain ‘down there’, sexual dysfunction (compromised erection, dyspareunia, pain with climax) or heaviness and pressure in the vaginal region (for women) [2]. A full list of sex-specific signs and symptoms of pelvic floor dysfunction can be seen in Table 1. Table 1 - signs and symptoms of pelvic floor dysfunction in men and women Who gets pelvic floor dysfunction? Pelvic floor dysfunction can affect any man, woman or child, however it is particularly problematic for women, especially during transitional life events, such as pregnancy/childbirth and the menopause [1]. One in three women will experience pelvic floor dysfunction [3] and for those that engage in sport, the prevalence of symptoms varies according to the load demands of the activity. For example 61% of netballers leak urine [4], up to 43% of female rugby players leak [5], and 32% of gymnasts experience incontinence [6]. Structural changes associated with vaginal childbirth and aging, as well as lower levels of oestrogen to lubricate and bulk out the tissues can increase the odds of experiencing pelvic floor dysfunction. However, even young adolescent females can leak urine due to the load demands of their sport. For example, in athletics and gymnastics, stress urinary incontinence (the involuntary leakage of urine during activities involving high levels of intra-abdominal pressure) is commonly experienced. Yet no-one is doing anything about it. No one is screening. No one is signposting. No one is educating these younger athletes that pelvic floor symptoms are not to be expected and normalised. Or that they simply indicate that the sporting demands exceed the load capacity at the pelvic floor. If this was any other area of sports or MSK practice, would we settle for a load capacity that does not meet the demands of the sport?! Why is this relevant to every therapist, no matter their di
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com