Solve the Medical Riddle: Her 14-year-old Daughter Had Knee Pain and Difficulty Climbing Stairs, Third Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

The first week of this riddle, the patient and her mother reported the patient’s symptoms to her PCP. The doctor proceeded with the examination using the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

The doctor ordered an X-ray of Julia’s knee and an MRI, and referred Julia to a physiatrist and a sports medicine doctor. The second week, we learned the results of Julia’s X-ray and MRI, and the  specialists did exams and conferred with the PCP. This week, we’ll let you know what some people have suggested as possible diagnoses. Next week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

Some Guesses as to What the Diagnosis Will Be

“I’m betting that the diagnosis is not the kind of tumor mentioned during the First Week of this Riddle! Wow! I hope I’m right. Anyway, here’s my guess: Maybe Julia has a chronic injury of her anterior cruciate ligament or ACL, or maybe a partial tear with some involvement of meniscus or cartilage tears. I studied ballet until I was 16 years old, and I kept quiet about my knee pain that started when I was 15 and landed really hard out of a jump on a stage that wasn’t “spring” or “floating.” When I finally gave in and told my teacher about the pain, it turned out that the meniscus was causing the pain and that the ACL issue could be serious down the road if the whole thing did tear. Ligaments don’t have any blood flow so you can’t feel pain if they tear but the ‘joint mice’ – little bits of meniscus cartilage that were trying to regrow – were jamming my knee and that really hurt. End of story, I have an arthroscopy to get the joint mice vacuumed out and I went to physical therapy to strengthen my quadriceps in order to prevent a full ACL tear. The quads are the four groups of muscles on the front, back, and sides of your thigh. I quit dancing when I went to college and took up swimming, which was safer for me. I wasn’t all that good at dancing anyway! So now I’m in my 50s and the ACL has never torn. Best of all, I’m pain free!”

— Lillian G.

“Could Julia have an infection such as chronic Lyme disease or maybe autoimmune arthritis? My cousin had knee pain from Lyme disease after she went camping with her family in Connecticut, and my sister has knee pain from rheumatoid or autoimmune arthritis. We have no idea what caused it! The doctor says it’s ‘idiopathic’, meaning no known cause.” But Julia’s kind of young for that, I think.”

— Jean R.

“Maybe Julia has a stress fracture. I know the doctor said Julia isn’t anorectic, which could cause bone loss, but my totally healthy and normal weight daughter got a stress fracture of her fifth metatarsal, her pinky toe, from dancing ballet on pointe when she was fifteen. The sports medic said my daughter’s foot had grown and that the pointe shoes were suddenly too tight. The only treatment was rest after some initial ice. My daughter missed out on ‘Nutcracker’ that year, which broke her heart, but she came back the next season. Whew!”

— Millie S.

“I’m a ballet teacher, so my guess is that Julia has chondromalacia. That’s a condition in which the cartilage in the knee cap wears away. However, I can tell you that Julia must have been going to a reputable dance school since she wasn’t put on pointe until she had sufficient training and her bones had ossified enough to take the stress. Full ossification doesn’t happen until about age 16 to 18 in girls, but the bones are strong enough in most students at about 10 or 11 to withstand the rigors of pointe work. I have my young students wiggle their noses with their fingers to teach about cartilage, and then I have them say ‘The inside of my toes is as soft as my nose.’ Then I explain that the cartilage in noses and ears and other places in the body always stay soft but that the cartilage in other places such as bones eventually gets hard or ossifies.”

— Marina O.

“My son, an avid soccer player, had a growth plate fracture in his knee when he was 14. Maybe that’s Julia’s diagnosis, although we were told that this type of fracture is much more common in boys than in girls. Also, growth plates close earlier in girls than boys. The growth plates are near the ends of children’s long bones. Even slight injuries can cause fractures since these plates are very soft. Adults would just get a joint sprain, but kids can get fractures that need immediate medical attention to prevent the limb from ending up crooked or too short.”

— Natalie T.

To be continued . . .

Come back to ThirdAge.com next Thursday when the doctor will reveal the actual diagnosis and treatment plan.

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.