Knee pain

Knee pain is common in children, most symptoms are caused by growth, overuse or muscle imbalance.

Common causes of knee pain:

1. Osgood-Schlatter (OS) and Sinding-Larsen-Johansson (SLJ) syndrome are traction apophysitis conditions in growing adolescents. With OS pain is located at the tibial tuberosity and with SLJ at the apex of the patella
2. Anterior knee pain is a dull, aching or sharp pain that can be felt behind, below or to the sides of the patella
3. Patella instability/dislocation

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Paediatric Red Flags

This list is not exhaustive nor a diagnostic tool, but areas to consider.

Children presenting with red flags, indicating the possibility of more serious underlying pathology, warrant urgent assessment, with some cases requiring referral directly to the Emergency Department or Acute Paediatrics.

Unremitting pain

• Night pain (Pain that awakens the child from sleep)
• Systemic symptoms; fever, malaise, unexplained weight loss, sickness
• Changes in bladder and bowel habit
• Hot, swollen and inflamed joint(s)
• Early morning stiffness (may indicate JIA) with persistent swelling
• Painful guarded movement/ muscle spasm/ significant loss of range of motion, in absence of trauma
• Regression of development / loss or deterioration of function
• Antalgic gait / inability to weight bear / gait disturbance / lower limb asymmetry
• Sensation changes (pins and needles/ numbness), absent or exaggerated reflexes, unexplained muscle weakness      

Action: Key assessment points

• Assess gait and function
• Check posture, leg length, symmetry/limb alignment
• Check range of movement of hips and knees and muscle flexibility
• Palpate knee to check for swelling and to ascertain area of pain
• Perform special tests to ligaments and menisci as indicated

Action: Referral not indicated

• Mild pain with no muscle tightness
• Educate and reassure parents/guardians.
• The majority of knee pain will resolve with improved flexibility and strength
• If acute knee injury and referral not required, go to provide family with acute knee injury leaflet

Action: Investigations

X-rays: Following trauma, suspicion of OCD: weight-bearing X-ray (AP, lateral)

Bloods: consider if inflammatory, infective or malignant cause suspected

Action: Refer to Paediatric Orthopaedics

• Suspicion of meniscal tear or ACL tear or other acute ligament injury
• Bony knee pathology
• Knee pain/functional limitation that is not resolving with physiotherapy
• Excessive or asymmetric deformity

Action: Refer to Acute Paediatrician

• A fever and/or red flags suggesting serious pathology
• Suspicion of non-accidental injury
• Abnormal neurology

Action: Refer to Podiatry or Orthotics

• Flat feet/calcaneo-valgus foot posture  accentuating lower limb position, causing knee/foot pain, rubbing or uneven shoe wear