Patellofemoral Syndrome

Having previously discussed Osgood Schlatter, let’s stick with this theme and turn to another very common knee problem, patellofemoral syndrome (PS).  PS is actually THE most common cause of knee pain from non-acute trauma in adolescents, in either athletes or those not engaged in organized physically competitive endeavors.

The hallmark of PS (sometimes called “chondromalacia of the patella which is actually only one form of PS) is pain in the knee just behind the kneecap (patella).  PS is also often called “runner’s” or “jumper’s” knee, because the problem is closely associated with, and exacerbated by, those activities/movements.  Kids with PS also commonly complain of worsening pain after sitting still for extended periods.  Some PS sufferers will note a popping or crackling sensation in the knee, especially upon climbing stairs.

No one knows the exact cause and in fact it likely has several contributing and compounding issues. The most common factor is wearing/thinning of the cartilage BEHIND the patella (NOT “meniscus”). The soft, smooth cartilage behind the kneecap and covering the lower end of the thighbone(“femur”) is a much more lubricated joint surface for movement than rough, hard bone. When/if that cartilage wears down it causes inflammation and pain.

The condition is usually brought on by some aspect of sub-optimal exercise/training routine: too much training, a sudden increase in training intensity, improper training technique,  using improper equipment(or proper equipment improperly) including footwear, bad or sudden change in training surface.

One common factor is quadriceps asymmetry.  The quadriceps is the main thigh muscle, responsible for straightening the leg at the knee by pulling the shin (“tibia”) forward at the knee joint.  As its name implies, the muscle has 4 parts, and if some sections are stronger/weaker than others the patella is not pulled straight through that cartilage lined groove at the bottom of the bone but rather will shimmy and bounce through it, causing the surface to wear down over time, leading to PS.

Thus a mainstay of treatment for PS is a good quadriceps strengthening program.  Also along those lines, I encourage athletes to avoid full “squats” generally and in particular if you have PS.  Half squats are usually ok. if they don’t cause pain.  If you must do full squats with weights, I encourage flexing the knee < 90 degrees and only use machines/apparatus where the weight is placed past the feet and pushed away from the body as opposed to the weight on the shoulders to be lifted.  A period of rest before return to sports is optimal or at least a modified training program limiting running/jumping outside of actual competition(substitute bike, low impact aerobic machines like elliptical trainer, swimming, water running). Heat before, ice after all vigorous activity. Wear a neoprene knee brace open at the patella for support during exercise. Anti-inflammatory medications like ibuprofen are often beneficial but not essential. 

Of course, if the pain is more disruptive or persistent then please come on in and let’s take a closer look together.  Thanks for following.


Knee pain/Osgood Schlatter

Last time we reviewed growth plate issues of the heel, so called Sever’s Disease. Please reference back to that article for a review of apophysitis.

Another location for this problem is just below the knee, so called Osgood Schlatter syndrome.  Here, we have the same basic problem: the powerful patella tendon pulls against the tibial (shin bone) growth plate as it undergoes rapid lengthening during puberty;  the tendon moves up the bone as it lengthens, causing inflammation and pain.

The location of the pain is quite specific: the “tibial tubercle”– that bump at the top of your shin just below your kneecap (see heading illustration). The area is typically swollen with at least mild redness and tenderness.  Like Sever’s in the heel, this apophysitis is a problem of early adolescence (10-13 girls, slightly more common in 12-14 boys), and is caused by the repetitive jumping action of some of the same sports– basketball, volleyball, soccer, plus additional ones like skating(figure and speed) as well as dance.

The problem is differentiated from another common knee problem “patellofemoral syndrome” (“chondromalacia”) which is PROBABLY (its controversial) caused by wearing of the lubricating cartilage behind the kneecap (not meniscal cartilage) where the pain is higher up and behind the kneecap, without the bump below the knee and with a somewhat duller pain. Meniscal cartilage tears, ligament and tendon damage almost always follow acute, more severe injury.  Old guys like me can have meniscal injury just from overuse and age; young athletes do not suffer from those problems–only damage from big hits to the joint can injure a kid’s knee.

Usually treatment involves pain management.  Nonsteroidal antiinlammatory drugs (NSAIDs) like ibuprofen and naproxen are the mainstay. A big part of the problem is generated by quadriceps tightness, so stretching and flexibility training is very important. Modify the athlete’s training/practice routine to limit overuse and allow for best competitive performance is key, so a good trainer and understanding/smart coaching is essential. A good knee pad that limits hits to the tender inflamed tibial tubercle provides relief from that problem.

Regarding overtraining, let’s recall as I think its important–max 2 seasons at one sport, a third season of a completely different one, and one season with only not organized general fitness training is my recommendation for limits to training schedule (less is certainly acceptable). Remember, Mom and Dad, we are talking about CHILDREN–they are supposed to have fun and free time.

If your younger teen is troubled by knee pain, give me a call and let’s discuss it.  Thanks for following.

Heel Pain/Sever Disease

Presently children will be starting fall sports training–football for boys, field hockey for girls, soccer and cross country for both.  Foot problems are a common problem for these athletes. About the most frequent foot complaint not caused by trauma that I see is heel pain, and most often the problem is a condition called Sever’s disease (note– I’ve heard the name pronounced to rhyme with “leather” or “weaver,” so take your pick).

The technical term here is “calcaneal (kal-KAY-knee-al) apophysitis (ah-pah-fis-I-tis). The calcaneus is the main bone of the heel; you can feel it at the bottom of the foot.  The apophysis, or growth plate, typically  doesn’t close until 12-14 in girls and 13-15 in boys, so that is the upper range to see this problem with beginning being onset of rapid growth, about 8-9 for girls, 9-11 for boys.

Sever’s disease is caused by the powerful Achilles tendon pulling against the open growth plate of a younger adolescent  when the bone is growing most rapidly. The pain results from the tendon pulling at the growth plate while actually moving along the bone over time as it is growing in order to maintain proper anatomic condition, coupled with the constant pounding at the heel while running.  Pain is sharp and can be elicited by pinching the heel with the fingers at either side.  Bilateral involvement is not uncommon. That is one way to differentiate it from some other problems with similar though subtly different symptoms. Stress fractures are almost always one sided and typically further up the foot.  Plantar fasciitis pain is also further forward at the heel/instep junction and usually gets worse with more running (“second step” pain).  Achilles tendonitis is usually behind the ankle and above the heel and hurts worse with jumping, when the Achilles pulls and the foot flexes down.

Although the discomfort is unsettling,  Sever’s disease is fortunately not serious.  It can certainly disrupt an athlete’s training or performance; however as the child reaches adult stature, the growth plate closes and the disorder will gradually resolve on its own without any longer term disability.  Treatment consists of modified training: less running outside of competition, more non-weight bearing aerobic training like biking, swimming, water running; non-steroidal pain medications like ibuprofen(avoid caffeine with this drug).   Cushioned insoles–either “off the rack” which can be purchased at shoe stores or custom made by your podiatrist (make sure they aren’t TOO thick) can be helpful.  If very disruptive a period of rest from sports and physical therapy will usually work.

Prevention is also key: proper shoes, stretching before playing, conditioning (its more common in overweight athletes).  Too much training is a problem here as well–DON’T OVERDO!!(my advise–max 1 sport for 2 seasons, a different sport for the 3rd and take the 4th season OFF–no formal competitive program).

If your child is experiencing foot pain please give me a call and let’s discuss it.  Send along questions or comments, and thanks for following.

Vaping, and your child

We see and hear more information every day regarding “e-cigarettes” or “electronic nicotine delivery systems”(“ENDS”).  Last year saw the largest one year increase in use among teens.  21% of teens reported using ENDS in the previous 30 days–up from 12% the previous year–representing a total of 1.5 million more teens vaping year over year. This is alarming.

There are many misconceptions and half truths about vaping:

  • Is it safer than cigarettes?  Probably yes, but that is a very low bar.  There is no evidence that, as claimed, it is safer for pregnant women or the developing fetus. In smoking adults ENDS are often used as a steppingstone in the quitting process. However the evidence of benefit so far is inconclusive and the US Preventive Service Task Force for smoking has not endorsed ENDS as a smoking cessation strategy.  In teens the effect is the opposite–kids tend to start out vaping and advance to cigarettes.
  • “Vape juice” is FDA approved.  This is a generally true statement but it is misleading. Many of the ingredients ARE approved–to CONSUME(eat).  The GI tract, of course, is very different from the pulmonary.  So you like orange juice?  In your lungs?
  • There are numerous chemicals contained in vape juice besides flavorings.  Only 13% of youths understood that they were inhaling nicotine. 70% of teens see no harm in its use.  However, besides nicotine, vape juice contains numerous known carcinogens, like diacetyl, formaldehyde, nitrosamines, benzene, as well as nickel, tin, and lead.

And there’s more.  Nicotine is known as a “gateway drug” which potentiates other drugs like cocaine,  and is associated with other illicit drug experimentation–marijuana, opiates, heroine, methamphetamines–as well as risky behaviors like binge drinking and early onset sex/more sexual partners.  Nicotine exposure increases the risk of poor focus and attention, lower impulse control, mood and anxiety disorders.

Vape juice is produced with sweet tasting flavors like mint, pina colada, mango which are specifically designed to appeal to youth.  Many of the strategies  employed by the ENDS industry mimic those of “Big Tobacco” to reach the youth market that were disallowed  by the tobacco liability settlement of 1998.

The current industry leader is JUUL, which has grown to dominate 75% of the market spearheaded by copious social media site advertising.  It comes in an elongated cartridge resembling a flash drive, designed to appeal as “sleek” and “cool” and has the added advantage of being easily concealed from parents view.  One JUUL cartridge contains the equivalent of 200 cigarette puffs of nicotine.

I urge all parents to be aware of the risks of these products to your child and to discuss them with your middle and high school children.  If you yourself are a smoker or a vaper–be aware: YOUR CHILDREN ARE WATCHING!

Here are some helpful websites with the above information:


Send along questions and comments, and thanks for following.

Pool Safety–Chemicals

My family has learned over the years to dread this week every May.  Pool opening–I turn into POOL MAN on a mission to turn a murky swamp into a pristine blue spa.  This year I did it in record time–barely 48 hours– from opening to crystal clear, and yesterday I enjoyed my first summer swim workout in my backward, always  a great day for me.

Let’s talk a bit about pool chemical safety.

US Emergency Rooms report >4500 pool chemical related injuries annually. >1/2 are at home, > 1/3 involve children and 2/3 occur in summertime (Memorial Day to Labor Day).  There has been little change in these numbers over the last 2 decades, but I find a bit positive in that number: given the increasing prevalence of back yard pools in our communities over that time, the static number of accidents probably means that we are doing a better safety job in this area, at least on the margins, anyway.

The most common accidents involve inhaled toxic fumes/dust; other common injuries occur to the eyes or skin.  Mostly this is due to accidental spread or splashing of powders or liquids or from fumes that arise from opening of containers.  Here are a few suggestions to help protect your family:

  • Keep all pool chemicals out of reach/contact of children or animals.
  • Read AND  FOLLOW directions for use carefully.
  • Whenever possible, wear protective gear–gloves, eyewear, even respirators–when handling pool chemicals.
  • Be cautious about any mixing of pool chemicals–especially chlorine and acids can pose particular dangers.
  • Storage rooms should have adequate ventilation and lighting.
  • Storage room interior should have enough temperature control to keep < 95 degrees F /35 C.
  • Storage rooms should be insulated to keep chemicals dry.
  • No smoking or flame around pool chemicals.
  • No power equipment or fuel around pool chemicals.
  • No food or beverage around pool chemicals.
  • Keep storage areas free of debris/refuse like rags, loose paper.
  • ALWAYS store chemicals in original, clearly marked containers.
  • Most chemical treatment guidelines recommend several hours after pool application prior to swimming.  Know those rules and follow them.
  • Poison control hotline number 1-800-222-1222.  24/7.


Please check out some of my “golden oldies” on pool/water safety from prior blog posts. Let the summer begin. Be safe and have fun!!

Send along questions and comments, and thanks for following.



High Caffeine “Energy” Drinks and Children

A recent article in my professional journal “Infectious Diseases in Children” by Bhargavi Kola MD and  Sandrine Defeu MPH reviewed important information regarding energy drinks consumed by children.  Let’s discuss.

Energy drinks claim to boost energy, confidence, athleticism, and immunity.  Red Bull was the 1st US brand marketed in the 90’s. Since then others have followed–popular names like Sobe Adrenaline Rush and No Fear, Amp Energy, Rock Star, Full Throttle, Monster.  They have lots of ingredients, but by far the most potent and impactful is caffeine.  Recall–caffeine is a DRUG with various effects on the body, the most significant being a stimulant. It wakes you up, increases heart rate and blood pressure.  Caffeine concentrations in these products vary; there are no official requirements from any government entity at any level to list them–it is completely up to the manufacturer to what extent that is done and ACCURATE.  The FDA places no limit on serving amount; 10mg caffeine/oz is common but some are loaded with up to 500mg/serving.  Note that the average cup of coffee has about 150mg; the AAP recommends a maximum dose for young people of 100mg/day.

These products are directly and aggressively marketed to youth through targeted TV ads and social media postings.  Yearly estimates show that young people have >120 viewing events annually for these sales pitches and 1/3 of teens report using energy drinks at least occasionally.  Kids drink them believing that they will make them more alert for school, driving, or to enhance workout performance and results.  There is no real data to support any of those assumptions: taking those drinks will wake you up but that is not nearly the same as greater concentration or performance and has nothing to do with workout efficiency; the immunity claims are little more than poppycock.

Unintentional effects are not uncommon.  I routinely see patients with sleep disruption caused by drinking this stuff. Other more concerning effects are increases in heart rate and hypertension, palpitations, headaches, abdominal pain or even GI bleeding, and anxiety.  There is lots of sugar(120-180mg) and sodium(340mg/8 oz) which can increase the risk of kidney disease or “metabolic syndrome”(hypertension, high lipids, adult diabetes).

In the US there are approximately 5000 calls to ER’s and poison centers regarding energy drink misuse, 2600 children <19 years and 90% of those will require treatment. Also recall that nowadays a substantial number of youth carry various psychiatric diagnoses treated with lots of different psychoactive medications (ADHD, depression, anxiety, even psychosis). There is almost no data on the interaction of caffeine with these potent agents.  Thus the AAP states “energy drinks have no place in the diet of children and adolescents.”

I concur. To be more awake get a full night’s rest; academic achievement comes from dedicated study and athletic performance from putting in the time and hard work to develop those strengths and skills(talent helps). None of these things can be found in a bottle and it’s vital that we as parents convey this reality to our children.

Thanks for following.

Air Quality and Child Safety

Let’s review 2 recent medical studies that can offer guidance on an important public policy issue.  The Lancet, a respected international medical journal, reported that worldwide >4 million children develop asthma annually from exposure to air pollution.  This represents 13% of new asthma diagnoses across the globe; the US was 3rd WORST in air quality (traffic fumes) caused asthma in this study.  Specifically nitrogen dioxide (NO2) concentration was the main culprit, but the study notes a strong correlation between NO2 and CO2 levels.

The occurrence, needless to say, was greater in urban compared to more rural areas, with the worst US cities being NYC, Los Angeles, Chicago, Las Vegas, and Milwaukee. Quoting the last sentence of the article–“Traffic emissions should be a target for exposure mitigations strategies.”

The second study, in the journal Environmental Research and conducted by the University of California, Merced and the National Institute of Health, analyzed data that calculated proximity to major roads and then compared parents’ reports of child development over their first 3 years. The investigators reported that being near major roads increased exposure to particulate matter (“PM2.5”)  and ozone, both prenatally and for those young children, was associated with developmental delay and impaired communication skills;  the incidence of these problems may double as a result of exposure to environmental hazards, the study suggests.  Again, the concluding sentence–“efforts to minimize air pollution exposure during critical development windows may be warranted.”

Consider this information in light of the present Administration’s proposal to freeze fuel emission standards in the year 2021 (as opposed to the present schedule to mandate greater efficiency standards through 2035). Their stated reason is that increasing those standards, as has been the policy for the past decade, compromises safety and increases fatalities.  However, these claims are contradicted by some of the government’s own data, by nonpartisan groups like Securing America’s Future Energy, industry groups like the Aluminum Association Transportation Group (which, please note, DOES have a vested interest in the subject) and even by officials presently serving in the government themselves. Many automakers oppose the idea as inefficient for them and expensive for consumers

Now, we hear arguments on either side of the climate change debate.  One can choose to accept that pollution causes climate change or not (and the comprehensive scientific conclusion is that it DOES).  As some skeptics like to say, “I am not a scientist”, therefore I cannot speak with any special authority about climate data.  But I am a pediatrician for 34 years, so I believe I am well qualified to address the pediatric medical literature. The above is only some of the information in my field telling us that pollution is bad for the wellbeing of the next generation, whatever you accept or reject about its effect on climate.  I say we ignore this at our children’s and grandchildren’s peril.

Please keep the above in mind as the debate–and political/election contests that are impacted by it–come before you this year, next year, and beyond.

Happy Easter and Passover to all and thanks for following.