What you “kneed”to know..
Do you like that title? “What you “kneed”to know?”
Anyway, I was watching my 9 year old daughter’s ice skating lesson yesterday and on the rink there were probably 50-75 kids, all divided up into various skill levels- there was the hockey crew, the tiny beginners (in helmets), the kids learning to go backwards, those learning to do swizzles and then some older kids doing spins. About 15 minutes into the lesson I noticed that at any given time at least 50% of the kids were at least half way horizontal on the ice. Falling backwards, down on one knee, down on both knees, seated. I’m pleased to report there were no apparent actual injuries and everyone appeared to just get right back up from body insults that looked like they would put me out of commission for at least 2 weeks. My knees were killing me just watching them fall down and then get back up, so it made me think I ought to talk about some KNEE STUFF. There’s the highly publicized ACL (ligament) tears that are fairly dramatic and usually require surgical repair and plenty of rehab, but what about the more subtle injuries?
The knees are weird and wonderful due to the amazing combination of muscles, bones, ligaments and tendons that make up its parts. It’s amazing how strong the knee really is, especially considering the beating that it takes.
First of all, can you break your knee?
Well, yes you can. You can fracture your kneecap (known as the patella in 25 cent language), but if you break the other bones that make up the knee you are technically breaking your leg (mostly femur or tibia). Breaking the kneecap is pretty unusual in children, though. Far more common is a DISLOCATED kneecap. This is not for the faint of heart, folks, because it’s when the kneecap slides from its normal location at the top of the knee to the inside or outside. It doesn’t look or feel great but it’s fairly simple to realign in most instances as a simple acute care or office procedure. A little pain medicine and leg manipulation and all the pieces parts are back in the right lineup.
In pediatrics, much of the time knee pain isn’t really from the knee at all. Kids point to their knees as the focal point of the pain but actually the problem lies in their hips or ankles, even. All of my orthopedic colleagues talk about checking out “the joint above and the joint below” the area in question and this makes sense to those people who are good at physics. Any misalignment in one joint alters the one related (for every action there’s an equal and opposite reaction, right?) so if the hip joint is not working correctly then of course the downstream effect on the knee will be similar. This happens in the case of a “SCFE,” or slipped capital femoral epiphysis, when the top of the thigh bone is out of alignment in the hip joint. Often kids with this condition will present with the complaint of –you guessed it– knee pain. So, the takeaway message here is that if your child complains of knee pain, it’s important to consider more than just knee problems as possibilities.
Additionally, there are so many ligaments and tendons in the knee that good old fashioned sprains, where the ligament or tendon gets overly stretched out and inflamed and angry, are quite common. These can be extremely painful and quite dramatic, with impressive swelling. (Another 25 cent word! We call the swelling an “effusion.”). The only effective treatment in this situation is rest and support, and that’s why your child might get an ENORMOUS knee immobilizer or brace and crutches, even if there’s nothing actually “broken.” Giving the inflamed ligament(s) a rest by not subjecting the leg to the force of walking can help the healing process. Taking anti-inflammatory medicine like ibuprofen can help as well. Correctly diagnosing the sprain takes some skilllzzzzz however, so it’s still important to get your child checked out if (s)he sustains a knee injury that you think “is probably ok.”
Knee joints can get infected, too.
That’s what we call a “septic knee” and can be quite serious, requiring irrigation and drainage of the joint and a lengthy course of IV antibiotics. It typically happens after some open trauma when bacteria get into the joint. Infected knee joints appear red and swollen and extremely tender, and kids with this are often ill appearing and have a fever. This situation requires immediate medical attention.
So I sat there thinking about all this while kids were going down HARD on the ice directly onto their kneecaps. 50-75 kids seemed to come off of the ice after their lesson without a fracture, sprain, dislocation or infection. How can you protect the knees in the first place during this kind of activity? Good ol’ fashioned KNEE PADS. I thought you “kneeded” to know this.