Knee Injuries

  • Michelle McTimoney
Part of the Contemporary Pediatric and Adolescent Sports Medicine book series (PASM)


Both acute and chronic knee injuries are common in the pediatric population. Although children and youth share many of the same musculoskeletal diagnoses as adults, there are many diagnoses that are specific to the athlete whose musculoskeletal system is still developing. It is essential to have a thorough understanding of both mature and developing knee anatomy in order to accurately diagnose and manage these injuries. Much of the clinical assessment is specific to anatomy, and an accurate diagnosis can often be made clinically at the bedside. Diagnosis can often be confirmed with plain imaging, CT scan, or MRI, depending on the specific injury considered. Once diagnosis has been confirmed, a collaborative approach to management is essential. The team may include physiotherapists, athletic therapists, and/or orthopedic surgeons in addition to the patient’s primary care physician. Together with an athlete’s coach, it is not only possible, but almost always desirable, to have the young athlete continue to participate in their sport with a tailored training schedule while they are rehabilitating their injury.


Apophysis Avulsion Fracture Growth plate/physis Physiotherapy Prevention Return to play Sprain Strain 


  1. 1.
    Public Health Agency of Canada Injury Surveillance Online, Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP). Distribution of all body parts touched by the injury. Accessed 22 Dec 2006.
  2. 2.
    Bernhardt DT. Knee and leg injuries. In: Birrer RB, Griesemer BA, Cataletto MB, editors. Pediatric sports medicine for primary care. Philadelphia: Lippincott, Williams & Wilkins; 2002.Google Scholar
  3. 3.
    Davids JR. Common orthopedic problems II. Pediatr Clin N Am. 1996;43(5):1067–90.CrossRefGoogle Scholar
  4. 4.
    Fithian DC, Paxton EW, Cohen AB. Indications in the treatment of patellar instability. J Knee Surg. 2004;17(1):47–56.CrossRefGoogle Scholar
  5. 5.
    Duthon VB. Acute traumatic patellar dislocation. Orthop Traumatol Surg Res. 2015;101(1 Suppl):S59–67.CrossRefGoogle Scholar
  6. 6.
    Stanitski CL. Patellar instability in the school age athlete. In: Dilworth Cannon W, editor. AAOS instructional course lectures, vol. 47. Rosemont: American Academy of Orthepedic Surgeons; 1998.Google Scholar
  7. 7.
    Virolainen H, Visure T, Kuseela T. Acute dislocations of the patella: MR findings. Radiology. 1993;189(1):243–6.CrossRefGoogle Scholar
  8. 8.
    Hinton RY, Sharma KM. Acute and recurrent patellar instability in the young athlete. Orthop Clin North Am. 2003;34(3):385–96.CrossRefGoogle Scholar
  9. 9.
    Maenpaa H, Lehto MU. Patellar dislocation. The long term results of nonoperated managements in 100 patients. Am J Sports Med. 1997;25(2):213–7.CrossRefGoogle Scholar
  10. 10.
    Longo UG, Ciuffreda M, Locher J, Berton A, Salvatore G, Denaro V. Treatment of primary acute patellar dislocation: systematic review and quantitative synthesis of the literature. Clin J Sport Med. 2017;27(6):511–23.CrossRefGoogle Scholar
  11. 11.
    Palmu S, Kallio PE, Donell ST, Helenius I, Nietosvaara Y. Acute patellar dislocation in children and adolescents: a randomized clinical trial. J Bone Joint Surg Am. 2008;90(3):463–70.CrossRefGoogle Scholar
  12. 12.
    Nikku R, Nietoscaara Y, Kallio PE, Aalto K, Michelsson JE. Operative versus closed treatment of primary dislocation of the patella: similar 2-year results in 125 randomized patients. Acta Orthop Scand. 1997;68(5):419–23.CrossRefGoogle Scholar
  13. 13.
    Andrade A, Thomas N. Randomized comparison of operative vs. non operative treatment following first time patellar dislocation. Presented at: The European Society of Sports Traumatology, Knee Surgery and Arthroscopy; April 2002; Rome, Italy.Google Scholar
  14. 14.
    Bales CP, Joseph HG, Moorman CT. Anterior cruciate ligament injuries in children with open physes. Am J Sport Med. 2004;32(8):1978–85.CrossRefGoogle Scholar
  15. 15.
    DeLee JC. Ligamentous injury of the knee. In: Stanitski CL, DeLee JC, Drez D, editors. Pediatric and adolescent sports medicine, vol. 3. Philadelphia: WB Saunders; 1994. p. 406–32.Google Scholar
  16. 16.
    Prince JS, Laor T, Bean JA. MRI of anterior cruciate ligament injuries and associated findings in the pediatric knee: changes with skeletal maturation. AJR Am J Roentgenol. 2005;185(3):756–62.CrossRefGoogle Scholar
  17. 17.
    Stracciolini A, Casciano R, Levey Friedman H, Stein CJ, Meehan WP 3rd, Micheli LJ. Pediatric sports injuries: a comparison of males vs females. Am J Sports Med. 2014;42(4):965–72.CrossRefGoogle Scholar
  18. 18.
    Huston LJ, Greenfield ML, Wojtys EM. Anterior cruciate ligament injuries in the female athlete: potential risk factors. Clin Orthop Rei Res. 2000;(372):50–63.CrossRefGoogle Scholar
  19. 19.
    Sugimoto D, Myer GD, Micheli LJ, Hewett TE. ABC’s of evidence-based anterior cruciate ligament injury prevention strategies in female athletes. Curr Phys Med Rehabil Rep. 2015;3(1):43–9.CrossRefGoogle Scholar
  20. 20.
    Dekker TJ, Rush JK, Schmitz MR. What’s new in pediatric and adolescent anterior cruciate ligament injuries? J Pediatr Orthop. 2018;38(3):185–92.CrossRefGoogle Scholar
  21. 21.
    Kocher MS, Garg S, Micheli LJ. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg. 2005;87A(11):2371–9.Google Scholar
  22. 22.
    Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Ganley TJ. Anterior cruciate ligament tears in children and adolescents: a meta analysis of nonoperative versus operative treatment. Am J Sports Med. 2014;42(11):2769–76.CrossRefGoogle Scholar
  23. 23.
    Kramer DE, Micheli LJ. Meniscal tears and discoid meniscus in children: diagnosis and treatment. J Am Acad Orthop Surg. 2009;17(11):698–707.CrossRefGoogle Scholar
  24. 24.
    Kocher MS, Klingele K, Rassman SO. Meniscal disorders: normal, discoid and cysts. Orthop Clin N Am. 2003;34(3):329–40.CrossRefGoogle Scholar
  25. 25.
    Kocher MS, Micheli LJ. The pediatric knee: evaluation and treatment. In: Insall JN, Scott WN, editors. Surgery of the knee. 3rd ed. New York: Churchill Livingstone; 2001. p. 1356–97.Google Scholar
  26. 26.
    Andrish JT. Meniscal injuries in children and adolescents. J Am Acad Orthop Surg. 1996;4(5):231–7.CrossRefGoogle Scholar
  27. 27.
    Kocher MS, Di Canzio J, Zurakowski D, Micheli LJ. Diagnostic performance of clinical examination and selective magnetic resonance images in the evaluation of intra-articular knee disorders in children and adolescents. Am J Sports Med. 2001;29(3):292–6.CrossRefGoogle Scholar
  28. 28.
    Mintzer CM, Richmond JC, Taylor J. Meniscal repair in the young athlete. Am J Sport Med. 1998;26(5):630–3.CrossRefGoogle Scholar
  29. 29.
    Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears that extend into the vascular zone in patients younger than twenty years of age. Am J Sports Med. 2002;30(4):589–600.CrossRefGoogle Scholar
  30. 30.
    Rubman MH, Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears that extend into the avascular zone: a review of 198 single and complex tears. Am J Sports Med. 1998;26(1):87–95.CrossRefGoogle Scholar
  31. 31.
    Diduch D, Scuderi GR, Scot WN. Knee injuries. In: Scuderi GR, McCann PD, editors. Sports medicine: a comprehensive approach. 2nd ed. Philadelphia: Elsevier; 2005. p. 346–87.CrossRefGoogle Scholar
  32. 32.
    Mosier SM, Stanitski CL. Acute tibial tubercle avulsion fractures. J Pediatr Orthop. 2004;24(2):181–4.CrossRefGoogle Scholar
  33. 33.
    McKoy BE, Stanitski CL. Acute tibial tubercle avulsion fracture. Orthop Clin N Am. 2003;34(3):397–403.CrossRefGoogle Scholar
  34. 34.
    Hand WL, Hand CR, Dunn AW. Avulsion fractures of the tibial tubercle. J Bone Joint Surg Am. 1971;53(8):1579–83.CrossRefGoogle Scholar
  35. 35.
    Stanitski CL. Acute tibial tubercle avulsion fracture. In: Stanitski CL, DeLee JC, Drez D, editors. Pediatric and adolescent sports medicine, vol. 3. Philadelphia: WB Saunders; 1994. p. 329–34.Google Scholar
  36. 36.
    Watson-Jones R. Fractures and joint injuries. 5th ed. Baltimore: Williams and Wilkins; 1976.Google Scholar
  37. 37.
    Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am. 1980;62(2):205–15.CrossRefGoogle Scholar
  38. 38.
    Pandya NK, Edmonds EW, Roocroft JH, Mubarak SJ. Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment. J Pediatr Orthop. 2012;32(8):749–59.CrossRefGoogle Scholar
  39. 39.
    Little RM, Milewski MD. Physeal fractures about the knee. Curr Rev Musculoskelet Med. 2016;9(4):478–86.CrossRefGoogle Scholar
  40. 40.
    Duri ZAA, Patel DV, Aichroth PM. The immature athlete. Clin Sports Med. 2002;21(3):461–82.CrossRefGoogle Scholar
  41. 41.
    Fairbank JC, Pynsent PB, van Poortvliet JA, Phillips H. Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg. 1984;66B(5):685–93.CrossRefGoogle Scholar
  42. 42.
    Crossley K, Bennell K, Green S, McConnell J. A systematic review of physical interventions for patellofemoral pain syndrome. Clin J Sport Med. 2001;11(2):103–10.CrossRefGoogle Scholar
  43. 43.
    van der Heijden RA, Lankhorst NE, van Linschoten R, Bierma-Zeinstra SMA, van Middelkoop M. Exercises for treating patellofemoral pain syndrome. Cochrane Database Syst Rev. 2015;1:CD010387.PubMedGoogle Scholar
  44. 44.
    Koshino T, Sugimoto K. New measurement of patellar height in the knees of children using the epiphyseal line midpoint. J Pediatr Orthop. 1989;9(2):216–8.CrossRefGoogle Scholar
  45. 45.
    Blackburn JS, Peel TYE. A new method of measuring patellar height. J Bone Joint Surg. 1977;59B(2):241–2.CrossRefGoogle Scholar
  46. 46.
    Panni AS, Biedirt RN, Maffulli N, Tartarone M, Romanini E. Overuse injuries of the extensor mechanism in athletes. Clin Sports Med. 2002;​21(3):483–98.CrossRefGoogle Scholar
  47. 47.
    Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clin N Am. 1995;26(3):547–59.Google Scholar
  48. 48.
    Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band friction syndrome. Clin J Sport Med. 2000;10(3):169–75.CrossRefGoogle Scholar
  49. 49.
    Fyfe I, Stanish WD. The use of eccentric training and stretching in the treatment and prevention of tendon injuries. Clin Sports Med. 1992;11(3):601–24.PubMedGoogle Scholar
  50. 50.
    Medlar RD, Lyne ED. Sinding-Larsen-Johansson disease. J Bone Joint Surg. 1978;60A(8):1112–6.Google Scholar
  51. 51.
    Osgood RB. Lesions of the tibial tubercle occurring during adolescence. Boston Med Surg J. 1903;148:114–7.CrossRefGoogle Scholar
  52. 52.
    Schlatter C. Verletzungen des schnabelforminogen fortsatzes der oberen tibiaepiphyse. Beitre Klin Chir Tubing. 1903;38:874–8.Google Scholar
  53. 53.
    Kujala UM, Kvist M, Heinonen O. Osgood Schlatter’s disease in adolescent athletes: retrospective study of incidence and duration. Am J Sports Med. 1985;13(4):236–41.CrossRefGoogle Scholar
  54. 54.
    Krause BL, Williams JP, Catteral A. Natural history of Osgood Schlatter’s disease. J Pediatr Orthop. 1990;10(1):65–9.CrossRefGoogle Scholar
  55. 55.
    Topol GA, Podesta LA, Reeves KD, Raya MF, Fullerton BD, Yeh HW. Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease. Pediatrics. 2011;128(5):e1121.CrossRefGoogle Scholar
  56. 56.
    Mital MA, Matza RA, Cohen J. The so–called unresolved Osgood Schlatter lesion. Clin Orthop. 1993;289:202–4.Google Scholar
  57. 57.
    Stanitski CL. Osteochondritis dissecans of the knee. In: Stanitski CL, DeLee JC, Drez D, editors. Pediatric and adolescent sports medicine, vol. 3. Philadelphia: W.B. Saunders; 1994. p. 387.Google Scholar
  58. 58.
    Wall E, Von Stein D. Juvenile osteochondritis dissecans. Orthop Clin N Am. 2003;34(3):341–53.CrossRefGoogle Scholar
  59. 59.
    Linden B. The incidence of osteochondritis dissecans in the condyles of the femur. Acta Orthop Scand. 1976;47(6):664–7.CrossRefGoogle Scholar
  60. 60.
    Hefti F, et al. Osteochondritis dissecans: a multicenter study of the European Pediatric Orthopedic Society. J Pediatr Orthop B. 1999;8(4):231–45.PubMedGoogle Scholar
  61. 61.
    Carroll NC, Mubarack SJ. Juvenile osteochondritis dissecans of the knee. J Bone Joint Surg. 1977;59B:506.Google Scholar
  62. 62.
    Litchman HM, McCullough RW, Gandsman EJ, et al. Computerized bloodflow analysis for decision making in the treatment of osteochondritis dissecans. J Pediatr Orthop. 1988;8(2):208–12.CrossRefGoogle Scholar
  63. 63.
    Cain EL, Clancy WG. Treatment algorithm for osteochondral injuries of the knee. Clin Sport Med. 2001;20(2):321–42.CrossRefGoogle Scholar
  64. 64.
    Milgram JW. Radiological and pathological manifestations of osteochondritis dissecans of the distal femur. Radiology. 1978;126(2):305–11.CrossRefGoogle Scholar
  65. 65.
    Cahill BR, Berg BC. 99m-Technetium phosphate compound joint scintigraphy in the management of juvenile OCD of the femoral condyles. Am J Sports Med. 1983;11(5):329–35.CrossRefGoogle Scholar
  66. 66.
    Cahill BR, Phillips MR, Navarro R. The results of conservative management of juvenile osteochondritis dissecans using joint scintigraphy. A prospective study. Am J Sports Med. 1989;17(5):601–5.CrossRefGoogle Scholar
  67. 67.
    Hughes JA, Cook JV, Churchill MA, Warren ME. Juvenile osteochondritis dissecans: a 5-year review of the natural history using clinical and MRI evaluation. Pediatr Radiol. 2003;33(6):410–7.CrossRefGoogle Scholar
  68. 68.
    O’Connor MA, Palaniappan M, Khan N, Bruce CE. Osteochondritis dissecans of the knee in children. J Bone Joint Surg. 2002;84B(2):259–62.Google Scholar
  69. 69.
    King JB, Cook JL, Khan KM, Maffulli N. Patellar tendinopathy. Sports Medicine Arthrosc Rev. 2000;8(1):86–95.CrossRefGoogle Scholar
  70. 70.
    Testa V, Capasso G, Maffulli N, et al. Ultrasound guided percutaneous longitudinal tenotomy for the management of patellar tendinopathy. Med Sci Sports Excerc. 1999;31(11):1509–15.CrossRefGoogle Scholar
  71. 71.
    Ferretti A, Ippolito E, Mariani PP, et al. Jumper’s knee. Am J Sports Med. 1983;11(2):58–62.CrossRefGoogle Scholar
  72. 72.
    Stanitski CL. Plica. In: Stanitski CL, DeLee JC, Drez D, editors. Pediatric and adolescent sports medicine, vol. 3. Philadelphia: WB Saunders; 1994. p. 317–9.Google Scholar
  73. 73.
    Rovere GD, Adair D. Medial synovial shelf plica syndrome; treatment by intraplical steroid injection. Am J Sports Med. 1985;13(6):383–6.CrossRefGoogle Scholar
  74. 74.
    Kelly BT, Green DW. Discoid lateral meniscus in children. Curr Opin Pediatr. 2002;14(1):54–61.CrossRefGoogle Scholar
  75. 75.
    Bellier G, Dupont JY, Larrin M, et al. Lateral discoid menisci in children. Arthroscopy. 1989;5(1):52–6.CrossRefGoogle Scholar
  76. 76.
    Watanabe M, Takada S, Ikeuchi H. Atlas of arthroscopy. Tokyo: Igaku-Shoin; 1969.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Michelle McTimoney
    • 1
  1. 1.Department of PediatricsAlberta Children’s HospitalCalgaryCanada

Personalised recommendations