Knee Pain in Children

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Knee pain is common at all ages

In young active adolescents, overuse with sports or exercise is an important cause of anterior knee pain

Children who are overweight are more prone to knee pain

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Signs and Symptoms

Be alert to red flags suggestive of malignancy, sepsis, non accidental injury

Be alert to any features that suggest inflammatory arthritis
Be alert to referred pain from the hip
Remember - normal variants should not cause pain

Anterior knee pain is common and encompasses a range of conditions that result in pain worse on exercise and likely relate to biomechanical factors such as patella tracking on flexion, leg alignment and foot posture

The figure attached shows common sites of tenderness with anterior knee pain

Be alert to red flags suggestive of

Malignancy (see link appendix ) – refer as 2WW to orthopaedics
Sepsis (see link appendix) - immediate referral to the emergency department
Non accidental injury (see link appendix) – refer to ED

Referral Criteria

The Table below summarises the causes of several conditions that can cause knee pain

Condition	Symptoms	Signs	Management	Refer To
Patellofemoral pain / chondromalacia patellae	Pain Worse with activity Pain or crepitus on patellar tracking	Genu valgum Hypermobility Tibial torsion Pronated forefeet	Physiotherapy Activity modification	Physiotherapy
Patella Dislocation	Pain	Dislocated patella	Reduction of patella Mobilisation	Physiotherapy – refer to orthopaedics if recurrent dislocation
Osgood Schlatter's disease	Pain on activity	Pain on resisted extension Tender (+/- swollen tibial tuberosity)	Ice Activity modification	Physiotherapy
Sinding-Larsen Johannson disease	Pain lower pole patella	Tender lower pole patella Worse on extension	Ice Physiotherapy Activity modification	Physiotherapy
Plica syndrome	Pain on flexion	May be tenderness	NSAID Activity modification	Physiotherapy
Osteochrondritis dissecans	Pain Locking Weakness		NSAIDs Intermittent locking, resolves without swelling, could be managed with period of analgesia	Orthopaedics
Loose body	Pain Locking Giving way Swelling	Tenderness, effusion, joint restriction	May need arthroscopic removal of loose body	Orthopaedics
Haemarthrosis	Pain Swelling (soon after injury)	Large, tense effusion Hamstring spasm	May need MRI / Aspiration	Orthopaedics - detail injury mechanism to allow decision re (+/-) MRI prior to review

Referral Instructions

e-Referral Service Selection

Specialty: Children's and Adolescent Services
Clinic Type: Orthopaedics
Service: DRSS-Western-Orthopaedics- Devon ICB-15N

Referral Form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: May 2017

Referral