Saoirse O’Sullivan: A 14-Year-Old Competitive Irish Dancer With Severe Left Anterior Knee Pain

Learning Objectives

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Learn the common causes of knee pain.
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Develop an understanding of the unique anatomy of the knee joint.
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Develop an understanding of the bursae of the knee.
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Develop an understanding of the causes of Osgood-Schlatter disease.
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Develop an understanding of the differential diagnosis of Osgood-Schlatter disease.
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Learn the clinical presentation of Osgood-Schlatter disease.
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Learn how to examine the knee, associated bursae, and the tibial tuberosity.
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Learn how to use physical examination to identify Osgood-Schlatter disease.
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Develop an understanding of the treatment options for Osgood-Schlatter disease.

Saoirse O’Sullivan

Saoirse O’Sullivan is a 14-year-old competitive Irish dancer with the chief complaint of “There’s a painful bump below my left knee and it’s embarrassing.” Saoirse stated that over the past several months, she has noticed a bump just below her left knee that has gotten bigger and bigger. Saoirse stated that over the past month, the pain has become so painful that it is difficult for her to practice for her Irish dance competitions. “Doctor, dancing is the most important thing in my life, and I want to get rid of this ugly bump on my knee. It’s hugely embarrassing to be up on stage and having everyone look at it. The pain is bad, too, but that bump just makes me want to cry.” I reassured her that I understood how she felt and would do everything I could to get it better. “So, Saoirse, have you ever had anything like this before?” She said, “No, Doctor, never.” “Any previous knee injuries?” I asked, and she again replied, “No, never.”

I asked Saoirse what made the pain worse and she said that dancing really made it hurt. I asked, “Anything else?” She said that any walking, going up and down stairs, and walking up the hill on her way to school—really any activity—made the pain worse. I asked her what made it better and she said that the pain got a lot better when she rested the knee, and she thought that Nuprin helped, but she was not allowed to take it when at school. She also thought that the heating pad felt good, but she didn’t like the way it made the bump so red. Saoirse denied significant sleep disturbance.

I asked Saoirse to point with one finger to show me where it hurt the most and she immediately pointed to the obviously enlarged tibial tuberosity ( Fig. 11.1 ).

On physical examination, Saoirse was afebrile. Her respirations were 16 and her pulse was 70 and regular. Her blood pressure was 106/72. Saoirse’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was normal. Visual inspection of the left knee revealed an enlarged tibial tuberosity on the left, which felt warm to touch but did not appear to be infected. The range of motion of the left knee was within normal limits. There was marked tenderness to palpation over the left tibial tuberosity, with the palpation of the area reproducing Saoirse’s pain. The right knee examination was normal, as was examination of her major joints. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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Gradual enlargement of the left tibial tuberosity
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Increase in pain in the area of the left tibial tuberosity
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Unhappy with cosmetic appearance of left knee
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Onset of left knee pain following Irish dancing
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Pain localized to the area of the left prepatellar region
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Pain associated with swelling of the affected knee
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Pain made worse by dance, walking, stairs, and walking up grades
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No other specific traumatic event to the area identified
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No fever or chills
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Unable to participate in competitive Irish dancing

The Physical Examination

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The patient is afebrile
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Obvious enlargement of the left tibial tuberosity
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Point tenderness to palpation of the area over the tibial tuberosity
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Palpation of left knee reveals warmth to touch
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No evidence of infection
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Normal range of motion of the affected knee

Other Findings of Note

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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No tenderness to deep palpation of the lumbar paraspinous muscles
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No peripheral edema
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Normal upper and lower extremity neurologic examination, motor and sensory examination
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Examinations of joints other than the left knee were normal

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiographs of the left knee
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Ultrasound of the left knee
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Magnetic resonance imaging (MRI) of the left knee

Test Results

The plain radiographs of the left knee reveal a prominent tibial tuberosity with an ossicle proximal to the tubercle (see Fig. 11.1 ). Ultrasound examination of the left knee revealed prepatellar bursitis and plica formation. Osteophyte and patella-femoral degenerative changes are noted ( Fig. 11.2 ). MRI reveals a prominent tibial tuberosity with marrow edema and associated thickening of the patellar tendon ( Fig. 11.3 ).