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

We’ll start this week by letting you know what the patient and her mother told her PCP and how the doctor proceeded with the examination. Next week, the PCP and specialists will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient and Her Mother Report the Symptoms

Claudia, age 55, brought her 14-year-old daughter, Julia, to the doctor because the teenager was complaining of fairly severe knee pain as well as difficulty climbing stairs.

As always in ThirdAge Medical Riddles, the doctor uses 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

This week, we’ll learn what Claudia and Julia told the PCP:

Claudia: “I’m so worried about Julia! She’s my surprise gift, the baby I had when I was 42 and our sons were already 10 and 12 years old. People will joke and call Julia the ‘caboose kid’ or my ‘menopause baby’, but those terms are so negative. Yes, the pregnancy was unexpected. However, my husband and I were beyond thrilled to have a daughter. The boys adore her, too. Julia has been a treasure since the day she was born. She was ‘good baby’ and she wasn’t a ‘terrible two’ at all. I won’t take credit for any of that. She just came this way! That’s exactly why I’m very concerned now. She absolutely never complains so that fact that she opened up and told me about the pain in her knee has to mean this is serious. She’s a budding ballerina, and she kept the pain to herself as long as she could because ‘Nutcracker’ rehearsals start in September at her dance school. She has been hoping to be cast a one of the young ‘Rosebuds’ on pointe with the older girls in ‘Waltz of the Flowers”. She’s been on pointe since she was 11 after training from the time she was in pre-ballet at age four. Maybe I should stop going on and on and let Julia speak for herself!”

Julia: “My mom is right that I was keeping this to myself and praying the pain would just go away. My dance teacher has taught us that if we ever have pain or minor injuries we should practice RICE – rest, ice, compression, elevation. I started putting ice on my knee and wrapping it with an elastic bandage and then putting my foot up on some pillows on a chair next to my desk when I was doing my homework. My teacher said to do this for fifteen minutes at a time with a two-hour break for 72 hours. After that time period, the therapy is no longer considered valid. I sneaked the ice upstairs to my room in a plastic bag every evening and followed my teacher’s instructions. The only thing I didn’t do was the ‘R’ for rest. I kept taking class during my ballet summer intensive because I wanted to be in shape for ‘Nutcracker’ auditions in the fall. Now, though, I can barely make it up the stairs to my room, and I also have to climb stairs at my school. Classes start at my ballet school on September 15th and the auditions are on September 19th. I really hope you can find out what’s wrong so I can try out for ‘Waltz of the Flowers’! That has been my dream ever since I was a little girl.”

While knee pain is rarely a medical emergency or associated with life threatening implications as so many of the diagnoses we have discussed previously in this column, it can be career threatening or just simply hugely impactful to a young adolescent’s life.

However, I am reminded of a young woman who came to me for knee pain. She turned out to have an osteosarcoma or bone cancer and required amputation. So to say knee pain is never life threatening is just not so. My patient was not a dancer. She was an active exerciser and runner who had months of intermittent but progressively worse pain in her knee. She was told knee pain was common in girls and simply tried to “live with it”. When I saw her for the first time I detected a subtle swelling in the area just above her patella. Fast forward through ultrasounds, an abnormal CT scan then MRI (done less often when I was first started in practice) and the diagnosis was made after a surgical biopsy. So never again would I suggest knee pain is not worthy of serious attention to exclude a serious cause, even in young adults!

This is why Julia’s doctor took her concerns seriously and spent extra time with Julia trying to get to the root of the problem. She first asked about the nature of the pain – when did it begin, what makes it worse or better, does it hurt her at night or when asleep, any associated swelling or history of injury or other medical conditions? Was her pain worse going up or down stairs? Or only after long periods of sitting? Was it more stiffness or pain? What happened if she knelt for long periods, as can happen in some choreography for groups or “corps de ballet”?

Julia recalled that the pain wasn’t sudden onset. She just gradually noted that when going up or down stairs at home and school, her knee would begin to hurt around the front of her kneecap. The pain could be severe at times, but she had no swelling or pain at night. She had never had an injury or accident and had never previously dislocated her knee.

Julia took no medications, including no birth control pills that can be associated with thrombophlebitis, a condition that occurs when a blood clot blocks one or more of the veins, typically in the legs, but knee pain is usually posterior and not anterior for that condition.

Her periods started at age 12 and they have been regular since, meaning she has no amenorrhea and that bone maturity had occurred. She had no history of anorexia, which can be linked to osteopenia, a precursor to osteoporosis that can result in severe bone loss.

During the physical exam, the doctor found normal height and weight and a very mild effusion, meaning fluid within the right knee joint, detected when the doctor was able to “ballot” the patella, meaning tap the patella (kneecap) with both hands compressing the knee in attempt to bring any fluid to the front of the knee joint. The doctor found no crepitus or crackling of knee joint with motion, and Julia had full normal ROM (range of motion) of the joint. She did have mild pain when the doctor compressed her patella.

Although the doctor knew that a plain X-ray rarely helps in the diagnosing of knee problems, she ordered a knee X-ray to assess integrity of joint space, maturity of bone growth, and rule out rare bone and joint diseases. The doctor also ordered an MRI that would allow for grading or scoring of the cartilage. A high MRI signal means abnormal cartilage.

The doctor referred Julia to a physiatrist, an MD with training in physical medicine, as well as to a sports medicine physician.

To be continued . . .

Come back to ThirdAge.com next Thursday to learn how the results of Julia’s X-ray and MRI, and to find out how the physiatrist and sports medicine specialist continued the quest for a correct diagnosis of Julia’s condition . . .

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.