Ultrasound Case of the Day: Patella Injuries in Adolescent Athletes

I saw a fascinating case last month.  The patient was a high level 13 year old baseball player who developed pain in the region of his knee cap (technically called the patella).

He did not have any traumatic injury, so I had a low suspicion of an injury like a patellar fracture, nor did I suspect a traumatic injury his ACL ligament or meniscus.

He was just starting his growth spurt.  Youth athletes are vulnerable to a different class of injuries than adult athletes.  The patellar ligament is what I call a structural complex, connecting the lower portion of the knee cap (the inferior pole of the patella) to a small bump on the shin called the tibial tuberosity.

This patellar ligament complex can be injured in different locations, depending on age:
- Age 11-12- at the inferior pole of the patella, an injury called Sinding-Larsen-Johannson syndrome
- Age 13-14- at the tibial tuberosity (where the patellar ligament attaches to the tibia)- called Osgood Schlatter syndrome.

The age ranges for SLJ and OS are approximate, but as a general rule SLJ occurs earlier in adolescence, and the more common OS occurs a few years later.   Their timing is based on when the bony processes, called an apophysis, fuses to the rest of the bone.

By late adolescence, the apophyses have fully fused, so we don't see these injuries much by an athlete's late 20s.  We may still see irregularities in the bone, but these are remnants of a prior injury, and rarely the cause of injury itself.  Instead, in athletes who are past puberty, the most common site of injury is within the patellar ligament itself (usually closer to the patella than the tibial tuberosity), a a condition called patellar tendinopathy, or jumper's knee.

In our clinic at Lake Washington Sports & Spine, Dr. Hyman and I like to use high-resolution musculoskeletal ultrasound to image the patellar ligament complex.  Ultrasound is a particularly great imaging tool for assessing tendons, for the following reasons:
1. It has the highest spatial resolution- 5-10 times higher than MRI
2. Real time assessment- it is the only imaging test that adds in actually touching the patient, so we can confirm that the area being imaged is actually painful.  This is particularly valuable in rough-and-tumble athletes with a history of prior injuries, to help clarify whether the injury is new
3. Fantastic tissue differential- ultrasound is great at distinguishing between different tissue types


To give an example of an ultrasound image of a patellar-ligament complex injury, the image below is that of Sinding Larsen Johannson syndrome in an 11 year-old elite-level soccer player.  The yellow box shows irregularity in the apophysis of the inferior pole of the patella (to help with orientation, left is superior, right is inferior)

Getting back to the 13 year old baseball player, based on his age and pain near the patella, I was anticipating that he may have SLJ syndrome.  However, his pain was located higher (on the superolateral portion of his knee cap).

Indeed, as the image below shows, the patella looked pristine in the center, with a smooth cortex

However, when I moved the probe laterally, I could see two disruptions in his cortex

This is a case of what is called a bipartite patella.   The superolateral portion of the patella never fused to the remaining part of the patella.  The x-ray image below shows the non-union of the bipartite patella, along with the planes of the two images above

How did I use this information clinically:
1. Relative non-use
2. Physical therapy.  Particular focus include stretching of the rectus femoris at the hip, since we wanted to limit traction of the quad distally
3. Avoiding NSAIDs.  The specific mechanism can interfere with healthy collagen synthesis, essential in this growing athlete
4. Regular icing

This athlete did great, and was able to return to sport in 1 month

Exercise Is Medicine! Dr. Hyman Trains with the US Medical Soccer Team in Atlanta (www.usmedicalsoccerteam.org)

May 2015

I just returned from a wonderful weekend devoted to community service, physician-kinship and arduous physical training in Atlanta, Georgia.

I met up with approximately 30 other physician colleagues from around the USA to prepare for our upcoming hosting of the World Medical Football Congress (WMFC), set to take place in Long Beach, CA, at the end of June 2015.  We are the US physicians who make up the US Medical Soccer Team (USMST).  (www.usmedicalsoccerteam.org)

We had 4 separate training sessions over the weekend and now I am enjoying a day of muscle recovery (but brain exercise) at work.  Our coach performed well to get us organized into a formation that should allow us to win games and make it to the knock out round of the tournament.

We arrived Friday afternoon, and met at the GW Carver Boys & Girls Club of Metro Atlanta, and we delivered our own “Healthy, Fit and Smart” education program to approximately 100 disadvantaged children.  The kids were wonderful — engaging, energetic, and with every small success answering our questions, their eyes beamed, and the potential for these children to absorb knowledge like sponges was palpable.  Highlights included one child answering ‘potassium’ as one of the 5 food groups (e.g. fruits, vegetables, grains, meats/fish, dairy), and another answering “eight hours a day” for the minimum time doctors recommend children watch TV (to be clear, there are no minimum daily requirements for TV watching!).  I think all of us doctors left the event grateful to the children from whom we continue to learn each time we deliver the Healthy, Fit and Smart program.

Our USMST potential is strong.  We will compete against physician national soccer teams from 18 different countries.  We’ve not made it past the early stages in prior tournaments.  In truth, we are a perennial underdog.  This year the team has several new physician-athletes, and we have high hopes to make our way to the knock out round of the tournament.

The physicians with whom I play are from all fields, and many are naturalized US citizens.  We have a trauma surgeon originally from Caracas, Venezuela, a vascular surgeon from Lima, Peru, an Internist from Romania, and a Family Physician from Trinidad and Tobago.  A good number of our physicians are originally from Iran.  We are a real melting pot.  Our dinner conversation usually surrounds soccer, but of course we banter quite a bit about medical topics as well.

So as our June training in Seattle and our summer tournament draw near, I reflect on how grateful I am that I can continue to push my fitness to new levels and compete on a ‘mini-world stage.’  I thank my family and my work team at LWSS without who's support I could not make this happen.

The danger of the "cost containment" industry

There is a recent article in the New Yorker that highlights the dangers of health care over-utilization.  It is a thoughtful, well-written article.

However, I suspect the governmental reaction to this article will be very anti-patient.  As an example, one of the major insurance companies we work with just published a bulletin requiring many musculoskeletal injections to undergo prior authorization by an outside company, CareCore National.  Their "Musculoskeletal Pain Management Criteria" document is 134 pages of guidelines that will limit what physicians are able to perform in office.

The current "big medicine" solution to over-utilization is to create an extra-layer in the health care process, and that extra layer has a large cost.  As a consequence, of the total money the US spends on health care, a higher % will go to administration, and a lower % will go to the actual delivery of care.

One of the terms that is thrown around a lot in medicine is "third party."  What patients need to recognize is that when there are increasing bureaucratic layers added in healthcare, the PATIENT becomes the third party.  We have many patients who have left big-system medicine practices and are now seen by us, because they are sick of being treated like a widget.  This happens because the physician is so busy focusing on compliance requirements from the insurance company and/or the health system where the physician is employed.

Are there people who abuse the system?  Of course!  But government intervention actually leads to MORE abuse.  For the small clinical practice who plays by the rules, these additional regulations just add additional cost and compliance burden, which gets in the way of good care.  There is only one class of doctors who afford the time and resources to hiring extra staff to handle specious treatments, and those are the serial abusers of the system.  The New Yorker itself did a fine expose piece in 2009 about these serial abusers in McAllen, Texas, who took advantage of low income, non-English speakers to run up costs.  This type of abuse would not be possible except that there are large central systems to manipulate, and because they were such abusers, it was worthwhile to devote resources to this manipulation.

We at Lake Washington Sports & Spine will continue to fight against this trend.  We will aim to be judicious in use of resources, but we will always prioritize the needs of the patient first.