Knees - Skiing

Abstract

HISTORY: A previously healthy 14-year-old female presents with left knee pain, stiffness, and swelling for one year after hearing a “pop” during a dance move. She is a competitive alpine skier and attends boarding school in Maine to pursue this. She was able to finish her skiing season, though continued to experience symptoms. MRI at that time showed effusion without associated ligamentous damage. Two weeks ago, her right knee began having similar symptoms. Her pain and stiffness in both knees are worse in the morning, after sitting for prolonged periods, and with stairs. PHYSICAL EXAMINATION: Patient has an antalgic gait pattern. The left knee has a tense effusion, with no soft tissue swelling, ecchymosis, or skin lesions. She has diffuse tenderness to palpation, especially along the medial femoral condyle. The right knee has a mild effusion and is not quite as tender. Both knees have full ROM, negative Lachman’s and Anterior Drawer, and are stable to varus/valgus stress. She has full strength and sensation. Exam is also notable for left elbow fullness, warmth, and decreased extension by 10 degrees, as well as B/L Achilles tendon fullness without associated tenderness. DIFFERNETIAL DX: 1. Inflammatory arthropathy 2. Synovial chondromatosis 3. Osteochondral defect 4. Lyme disease 5. Autoimmune process TESTS / RESULTS: -B/L knee XRs: no obvious abnormalities or defects. -MRI left knee: large joint effusion with extensive tiny loose bodies (typical appearance of “rice bodies”). No meniscal, chondral, or ligamentous pathology. -Lyme negative -CRP and ESR elevated - (+) ANA -RF negative FINAL / WORKING DX: Juvenile Rheumatoid Arthritis (JRA) TREATMENT & OUTCOMES: -Strict activity modification, anti-inflammatories, ice, elevation, pediatric rheumatology referral, arthroscopic debridement of B/L knees with synovial biopsies. -Rheumatology performed an intra-articular steroid injection of B/L knee joints, initiated DMARD therapy with Methotrexate, and referred for expedited ophthalmology evaluation. -On post-op f/u, pathology findings were reviewed, which were consistent with JRA. -At 1 month post-op debridement and 2 months s/p initiation of DMARDs, patient has no swelling or pain and is undergoing progressive return to full activities (including skiing) as tolerated under the guidance of her athletic trainer.