SCFE (Iliotibial band syndrome, Legg-Calvé-Perthes, AVN)
- Onset may be sudden, but more often it is
- Pain frequently is referred to the
knee, but it also can occur in the
- Limp and out-toeing, as
reported for the boy in the vignette, are common.
- "painful limp" (vs painless limp in Legg-Calves-Perthe)
- limitation of medial rotation
- pain on passive motion
- obligate external rotation of hip
- flexion at hip
- An anterior-posterior or frog-leg lateral radiograph of the hip generally
reveals the abnormality (get BOTH views); frog-leg lateral x-ray is most
sensitive for picking up early slip; AP view may show irregularity and
widening of growth plate
- “ice cream cone” sign best seen on frog leg view
- may be associated with endocrine (e.g., hypothyroidism) or systemic
disorders (e.g., rickets)
- Emergency!!! To Ortho in wheelchair!!
- includes pinning of epiphysis to prevent further slip;
possible osteotomies in future.
Osteomyelitis often presents with fever and localized pain and should
be considered in any child who has a limp. It usually is associated with an
elevated erythrocyte sedimentation rate.
A cruciate ligament tear generally results from significant trauma and
is characterized by severe pain and an obvious knee effusion.
Avascular necrosis (AVN) of the femoral head
Iliotibial band syndrome
- is a common injury among runners because of the repetitive nature of their
- It involves inflammation of the
band from rubbing over the lateral femoral condyle, sometimes causing a
snapping sensation during flexion or
- The iliotibial band itself is a thickened strip of fascia that extends
from the tubercle of the iliac crest and provides the insertion for the tensor
fascia lata and gluteus maximus muscles. The
band continues down the lateral side of the leg, and in conjunction with the
ultimately attaches onto the lateral tubercle of the tibia (
tubercle ) and lateral proximal fibular head. A bursa located at this
attachment facilitates movement of the iliotibial band over the lateral
epicondyle. The iliotibial band's primary function is to provide static
stability to the lateral aspect of the knee.
When the knee is flexed to an angle greater than 30 degrees, the
band shifts posteriorly
behind the lateral femoral
epicondyle. During knee
extension, the band shifts
anteriorly in front of the
lateral femoral epicondyle.
It is this motion that commonly leads to irritation and inflammation within
the iliotibial band, bursa, and the periosteum of the lateral femoral
- It is not uncommon then to have an absence of pain with stiff-legged
walking by the athlete suffering from ITBFS. Logically this type of gait would
remove the problematic friction that the sliding ITB causes.
- As described by Southmayd and Hoffman (15) ITBFS usually starts with minor
discomfort, and becomes progressively worse. Sometimes it begins after a
single run. "I felt particularly good, so I ran an extra three miles, and the
pain developed after the run" is a common scenario. The pain is located almost
always on the outer aspect of the knee
- Most sufferers of ITBFS cannot put their finger on one particular tender
spot. They will usually use the flat of their hand to describe the location of
- Structural anatomical abnormalities also put the athlete at risk. By
carefully inspecting the areas around the affected site we should be able to
identify an ITB problem.
- Some structural abnormalities identified during inspection can be leg
length discrepancy. The effects are a lateral pelvic tilt which results in a
tightening of the ITB on the lower leg and thus causing a higher chance for
- Another inspectable abnormality might be excessive pronation or Cavus
feet. An inspection of the patients footwear might clue us on to this.
Pronation of the foot causes the tibia to rotate internally and in
consequence, tightens the ITB.
- Thirdly, we should notice a genu varum condition, an increase in the
angle of the femur and the tibia (valgus 170 to 175 degrees). This also
results in a tightened ITB across the knee joint.
- A condition known as osteonecrosis, having a prominent lateral femoral
condyle has been associated with ITBFS. Once structural abnormalities have
been introduced we must remember to also make an observation regarding
swelling and/or discoloration.
- Careful palpation of the affected area is the next step in the evaluation
process. A patient with
will exhibit extreme point tenderness about two cm. over the joint line when
the knee is flexed at thirty degrees and palpated over the lateral femoral
Active flexion and extension of the knee may produce what can be said to be a
"creaking" sound. During palpation, care must be taken to rule out
other knee pathologies. One of the key points about ITBFS is that it is a
problem not inside the knee joint, but around it. In this way, it can be
easily distinguished from internal knee-joint problems such as a torn
cartilage or ligament or loose body ( a joint mouse )
- The first phase of care is the Immediate Phase. This is the phase in which
pain and inflammation are to be controlled, requiring a reduction of activity
and the appropriate administration of oral anti-inflammatories. Numerous
modalities may be implemented at this point if deemed advantageous by the
trainer. Such appropriate treatments may include; ice, heat, ultrasound,
and/or electrical stimulation. It must also be noted that stretching exercises
are also used here to combat any excessive ITB tightness.
- Phase two, or the Short Term Phase, becomes a consideration if painful
symptoms do not resolve within approximately 10 days of the documented
onset. Previous treatment should be continued at this point with the possible
addition of physician administered steroid injections (given in 2-week
intervals) and further restriction of activity may be a necessity.
- If deconditioning of the athlete becomes a concern during this phase of
rehabilitation, he/she may participate in other activities such as swimming or
cycling so long as the activity remains pain-free.
- The third, and optimistically final, stage of the treatment is known as
the Long Term Phase, begins only after pain and inflammation are resolved and
typically in close association with the athlete's return to sport. During this
stage, it is of utmost importance to prevent any reoccurrence of the resolved
symptoms. A gradual return to play with extensive structurally specific
stretching exercises both before and after workout is essential to ensure
- If training errors have not been corrected or inflammation significantly
reduced, return to activity will not be satisfactory.
Baskin MN. Injury—knee. In: Fleisher GR, Ludwig S, eds. Textbook of
Pediatric Emergency Medicine. 4th ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2000:339-347
Richards BS. Slipped capital femoral epiphysis. Pediatr Rev. 1996;17: 69-70
Staheli LT. Hip. In: Fundamentals of Pediatric Orthopedics. 2nd ed.
Philadelphia, Pa: Lippincott-Raven; 1998:68-71