Knee pain in Adolescents
Understanding Adolescent Knee Pain: More Than Just Growing Pains
Knee pain is a common issue for many, including adolescents. While it’s often brushed off as "growing pains," recent research suggests that adolescent knee pain, particularly Patellofemoral Pain (PFP), may not simply resolve with age. In fact, many teens continue to experience knee pain into adulthood, impacting their quality of life. As physiotherapists, it's crucial to recognize when knee pain in young people might be a sign of something more serious, like patellofemoral joint instability, and provide effective treatment to prevent long-term issues.
The Prevalence of Adolescent PFP
Patellofemoral pain affects up to 28.9% of adolescents, and a concerning 75% of them continue to experience pain a year after its onset. PFP is rarely caused by a single factor. Instead, it’s typically a result of various contributing elements, including physical activity levels and biomechanical issues. Many teens affected by PFP are highly active, participating in multiple sports or engaging in daily activities that place significant stress on their knees—such as climbing stairs or kneeling for extended periods. These demands on the Patellofemoral Joint (PFJ) increase the likelihood of pain.
Promising Treatment Approaches
Proper management of adolescent knee pain requires a holistic approach. One notable study by Rathleff et al. (2019) demonstrated the benefits of load management in reducing PFP symptoms. In this study, participants significantly decreased activity levels for four weeks, followed by a gradual reintroduction of movement over three weeks through targeted exercises. The results were remarkable: 68% of participants returned to sport within three months, and that number increased to 81% after a year, all while showing improvements in pain and overall quality of life.
This emphasizes the importance of identifying high-demand activities that may aggravate the knee, allowing for tailored rehabilitation that addresses the root causes of pain.
Beyond Physical Pain: The Emotional Impact
Knee pain in adolescents doesn't just affect physical well-being; it can also take a toll on their mental health. Teens with PFP often experience feelings of worry, sadness, and frustration due to their pain. More than half of those affected are acutely aware of their knee issues on a daily basis. This awareness can lead to kinesiophobia, a fear of movement, which only worsens the problem by creating altered movement patterns that perpetuate pain.
To address this, educating patients about the nature of their pain is essential. Explain what PFP is, why it happens, and what they can do to regain control. This not only helps reduce their fear but also tackles issues like pain catastrophizing and avoidance, ultimately promoting better outcomes.
Patellofemoral Instability: A Key Factor in Adolescent Knee Pain
For some adolescents, knee pain is more than just overload or external factors—patellofemoral instability may be a major contributor. Patellar instability occurs when the kneecap moves excessively within its groove, leading to discomfort or, in more severe cases, dislocation.
Intrinsic factors such as anatomical anomalies—like a shallow trochlea or high-riding patella—can contribute to instability. While these factors can't always be changed, understanding them is vital for designing effective treatment. For instance, if a high patella delays stability during the initial 40 degrees of knee flexion, focusing therapy on strengthening the knee in this range can enhance dynamic stability.
Fortunately, many other factors related to instability can be modified through targeted physiotherapy, including weak quadriceps, poor proximal control, and excessive foot movement. Addressing these areas helps improve knee stability and reduce the risk of future dislocations.
Physiotherapy Treatment: What to Include
Physiotherapy for adolescent knee pain should be personalized, but there are key elements that benefit most patients:
Education and Confidence Building – Helping patients understand their condition and empowering them with the tools to manage it is crucial.
Swelling Management – Swelling can inhibit the vastus medialis muscle, which is vital for knee stability. Simple techniques, like icing before exercise, can reduce swelling and pain, allowing for safer rehabilitation.
Exercise Selection – Begin with closed kinetic chain exercises within a range of 0 to 50 degrees of knee flexion, as these are less likely to aggravate the PFJ. Progress to open kinetic chain exercises as tolerated.
Dynamic Stability Training – Strengthen the entire kinetic chain, including the trunk and lower extremities, to enhance overall stability and compensate for structural vulnerabilities.
Proprioceptive Training – Balance and proprioception exercises should be incorporated to improve neuromuscular control, which is crucial for preventing re-injury.
When Surgery Might Be Necessary
In severe cases of patellofemoral instability, especially those involving recurrent subluxation or dislocation, surgical intervention may be required. Factors like trochlear dysplasia or a long patellar tendon can increase the likelihood of future dislocations, particularly in adolescents under the age of 13 who have already experienced a dislocation.
However, it’s important to manage expectations when discussing surgery with patients and their parents. Not all cases of instability require surgery, and a well-structured physiotherapy program can still offer significant benefits for many.
Conclusion: Adolescent Knee Pain is Not Always "Just Growing Pains"
Adolescent knee pain, particularly PFP, should be taken seriously. While it’s tempting to dismiss it as growing pains, doing so could lead to prolonged pain and reduced quality of life. By recognizing the treatable aspects, such as patellofemoral instability, and implementing evidence-based physiotherapy interventions, we can help adolescents regain control over their knee health and prevent long-term issues.
If your adolescent patient is experiencing knee pain that isn't improving, be aware of other conditions that may present similarly, like Osgood-Schlatter disease or Sinding-Larsen-Johansson syndrome. A thorough assessment and personalized treatment plan can make all the difference in helping them recover and get back to their active lifestyle.
