Sports Medicine

Patello-Femoral (Kneecap) Pain & Instability

What is the Patello-Femoral Joint (PFJ)?

The patella (kneecap) is the bone at the front of the knee joint. The patellar tendon and quadriceps tendon attach the kneecap to the tibia (below the knee) and the femur (above the knee). When your child bends or straightens their knee, the underside of the kneecap glides through a groove made by these big leg bones at the knee.

When the kneecap does not move properly within this groove at the lower part of the thigh bone, it can result in anterior knee pain.

Anterior knee pain is pain at the front of the knee; it can be due to several causes:

• Patella Chondromalacia – softening or wearing out of the cartilage under the kneecap (patella)
• Patella Instability – the sensation of the kneecap wanting to “pop” out
• Inflammation of the tendon insertion sites – where the kneecap attaches to the shin bone (patella tendon) or where the top of the kneecap attaches to the thigh muscles (quadriceps tendon)
• Abnormal alignment of the lower limb – especially rotation problems
• Dislocations or ligament injuries – Patella dislocations or Medial Patello- Femoral Ligament ruptures
• Direct blows that may cause fractures or cartilage injuries – Osteochondral fractures

Some common names for these problems include Jumper’s knee, Patello-femoral syndrome, Chondromalacia patella, and Osgood-Schlatter’s Disease.

While anterior knee pain can affect anyone, it happens more often in:
• Teenage girls and young women
• Flexible (ligamentously lax) people
• Sporty children, particularly those who jump, run or ski
• Overweight people
• Patients who have previously dislocated their knee

Anterior knee pain usually presents as a vague, aching pain behind the kneecap that is worst when your child goes downstairs, runs downhill or squats. The pain can be sharp and severe in acute injuries, resulting in the leg “giving way”.
A common symptom is a grinding sensation (like crunching bones) when the knee is bent and a sensation of the kneecap wanting to “pop” out when the patella is stressed.

If your child or teenager complains of anterior knee pain, they should be reviewed by an experienced paediatric orthopaedic surgeon.

At VicOrtho, our expert surgeons will take a thorough history, examine them, assess their pain and use specialised diagnostic imaging to diagnose the problem before we work with you and your child to develop their treatment plan.

In most cases, your child’s anterior knee pain can be treated with a variety of non-surgical options. Occasionally, surgery may be recommended.

Non-surgical treatment may include:
• Resting the knee and taking NSAIDs to help relieve pain
• Modifying your child’s activity i.e. changing the way they exercise
• Exercising to strengthen and stretch the quadriceps and hamstring muscles
• Weight management (if appropriate)

If your child’s anterior knee pain cannot be treated non-surgically, we may recommend surgery to treat the problem.
During surgery, any damaged kneecap cartilage will be addressed. The ligaments and tendons around the patella may be reconstructed or adjusted to help realign the kneecap.

Osteochondritis Dissecans

What is Osteochondritis Dissecans (OCD)?

Osteochondritis dissecans (OCD) is a joint condition that occurs when a piece of cartilage and the thin layer of bone deep to it, separates from the end of the bone. OCD most often affects the knee but may also affect the elbow and ankle amongst other bones.

The exact cause of osteochondritis dissecans is unknown however, OCD may stem from:
• Microtrauma from repetitive use of the affected joint
• Reduced blood supply to the bone
• Genetic factors

Symptoms of osteochondritis dissecans are highly variable between children. The most common symptoms of OCD include pain, swelling, locking or “catching” of the affected joint, increased pain with activity, and a “giving way” sensation in the affected area.

At VicOrtho, our surgeons will take a thorough medical history, evaluate your child’s pain, examine your child and refer for appropriate imaging in order to diagnose the condition. With all this information on board, we will then discuss with you a tailored plan for their treatment.

The first step in treating OCD is to modify your child’s activities. Your child may need to temporarily change or pause their sport of choice.

Non-surgical treatment options include:

• Activity modification – closed kinetic chain exercises
• Immobilisation
• Protected weight-bearing exercises

If non-operative treatment doesn’t result in improvement – surgical intervention may be necessary.
Surgery for OCD will:

• Address & reattach the loose piece of the cartilage/bone
• Stimulate new bone formation

You child will continue to be monitored regularly by us to ensure any problems are spotted and treated as soon as possible. During follow-up visits, X-rays and other diagnostic testing may be done. The goal of continued monitoring is to help spot any irregularities in growth or development and to address issues as they develop.

Anterior Cruciate Ligament (ACL Injuries)

What are ACL injuries?

Anterior cruciate ligament (ACL) ruptures are common knee injuries and can occur in childhood, adolescence, and adulthood. ACL injuries occur more commonly in sports with a lot of running, jumping and changing directions; football, soccer, netball, and basketball. Some ACL injuries will require surgery. Often, there are other injuries that occur at the same time as the ACL injury, namely meniscal tears, collateral ligament injuries and damage to cartilage.

The Knee is the junction of 3 bones:
• Femur (thighbone)
• Tibia (shinbone)
• Patella (kneecap)

The ligaments that keep the knee joint stable are:

• The medial & lateral collateral ligament that run on the inner and outer side of the knee between the femur and tibia. These ligaments control the sideways movement of the knee.

• Anterior and posterior cruciate ligaments run diagonally inside the knee joint to form an “X”. These ligaments control the forward and backward movement of the knee. The ACL stops the femur sliding off the back of the tibia.

ACL injuries can be caused by:
• Abrupt stopping motions
• Sudden changes in direction while running
• Jumping or landing incorrectly
• Contact injuries, such as a footy/soccer tackles
• Pivoting motions

If your child injuries his ACL, they may:
• Hear a popping sound
• Feel as if their knee has given out from under them
• Experience immediate pain and swelling
• Be unable to continue playing immediately after the injury
• Lose full range of motion
• Experience joint tenderness

A child or adolescent with a suspected ACL injury should be evaluated by an orthopeadic surgeon experienced in treating children and young people with such injuries.

At VicOrtho, we will perform a physical exam of your child, specifically addressing all structures of the injured knee, and comparing them to the non-injured knee.

We will assess your child’s pain, discuss their child’s medical history and arrange diagnostic imaging to help diagnose your child’s condition and the severity of the injury.

Then, we will work with you and your child to develop an individualized treatment plan.

Treatment for your child’s ACL injury will depend on a number of factors, including your child’s age and development, the severity of the injury, and long-term goals.

Non-surgical options include:
• Activity modification
• Brace immobilisation, followed by physiotherapy guided intensive injury rehabilitation
• Functional testing to assess suitability for return to activity

A torn ACL will not heal without surgery, but it is not appropriate for everyone.

ACL reconstruction surgery is recommended for:

• Adolescents, young adults and adults who report ongoing instability despite physiotherapy guided injury rehabilitation
• Patients with complete ACL ruptures
• Individuals who want to continue to be involved in competitive sports that require cutting and twisting (i.e. football, soccer, basketball, and netball)
• Surgery for children who are still growing and have open growth plates requires particular expertise to stabilise the knee whilst preserving the growth plate

ACL reconstruction is typically performed arthroscopically, which is less invasive than open surgery and allows patients to recover more quickly. During this procedure, we will make smaller incisions to minimise trauma to the knee.

Because most ACL tears cannot simply be stitched back together, orthopaedic surgeons must recreate the ligament using a tissue graft to act as “scaffolding” for the new ligament to grow onto.

Most ACL reconstruction procedures are not done right away after injury. Instead, the preference is to wait until swelling has decreased and joint motion has returned. If an ACL reconstruction is performed too early, there is a significantly increased risk of arthrofibrosis (scar tissue forming in the joint) which could lead to loss of knee motion.

Rehabilitation is vital for recovery after an ACL injury — even if your child did not have surgery. Physical therapy will help your child regain strength and motion in their knee and leg.

If your child had surgery, rehabilitation will initially focus on returning motion to the knee and leg muscles followed by a strengthening program designed to protect the new ligament by gradually increasing stress on the ligament. Finally, your child will participate in a customized program designed to optimise return to their chosen sport.

Healing of the ACL takes time. It’s important to help your child have realistic expectations about their recovery. It may be six months or more – depending on strength and agility training — before an athlete can return to sports after surgery.

Meniscal Tears

What are meniscal tears?

Meniscus tears are a common knee injury. Anyone can tear their meniscus, but it is more common in athletes, especially in contacts sports, with sudden and forceful twisting of the knee.

The meniscus is a semicircular, wedge of soft tissue in the knee that acts as a cushion between the femur (thigh bone) and the tibia (shin bone).

A unique type of meniscus problem occasionally encountered in children is an abnormally shaped meniscus called a discoid meniscus. The disc shape of these menisci makes them more susceptible to tearing.

Symptoms of a meniscus tear can include:

• Pain in the knee joint
• Swelling
• Occasionally a “catching” sensation toward the side or back of the knee
• Locking and loss of range of motion

If you suspect your child or teen has a meniscus tear, he should be evaluated by an experienced orthopaedic surgeon.
At VicOrtho, we will take a thorough medical history, examine your child, assess their pain and perform diagnostic imaging to diagnose the problem. Then, we will work with you and your child to develop their individualized treatment plan.

Children have a better blood supply to their meniscus than adults and, in some cases, can heal certain patterns of meniscal tears with non-surgical treatments. If the tear is too serious, however, surgery may be recommended.

Non-surgical options include:

• Activity modification
• Brace immobilisation, followed by physiotherapy guided intensive injury rehabilitation
• Functional testing to assess suitability for return to activity

Arthroscopic-assisted surgery is recommended for meniscal tears that do not heal despite non-operative management.
During this procedure, the orthopaedic surgeon will make small incisions that create minimal trauma to your child’s knee. Repairable portions of the meniscus will be fixed with sutures or a material that holds the meniscus together while it is healing. When the meniscus is healed, your child’s body will safely absorb this material.