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

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 specialists did exams and conferred with the PCP. This week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

The Doctor Reveals the Diagnosis

Marina O., the ballet teacher, nailed the diagnosis! Julia does indeed have chondromalacia, the softening and wearing away of the cartilage in the kneecap. This condition is fairly common among teenage ballet students. Although the long-range prognosis is good, the short term issues for would-be ballerinas can be distressing. Julia needs to reduce strenuous activates, which probably means she won’t be able to fulfill her dream this year of dancing on pointe in the “Waltz of the Flowers” in her studio’s annual “Nutcracker”. Predictably, she burst into tears when I broke that news to her as gently as possible. I did reassure her that she would no doubt be in fine shape again for the studio’s annual Spring Showcase in May. Julia turned out to be a real trouper who volunteered to help with the “Nutcracker” boutique and also help with costumes and props and rehearsed the younger children in the production. Her mother says that made her proud of her daughter, as well it should have.

In the meantime, I recommended that Julia take Advil or another OTC pain reliever if she had severe pain, but I cautioned that she shouldn’t do that too often. She agreed and did comply with my instructions. I also used this opportunity to discuss the importance of good nutrition and exercise in healthy bone growth and avoiding osteoporosis down the line.

The prognosis for Julia is good, meaning that operative treatment probably won’t be necessary. For more severe cases, these are possibilities: arthroscopic debridement (lavage or cleaning out and washing and rinsing out the knee; articular resurfacing, surgical correction of any instability; removal of the patella.

In addition, as Lillian G. mentioned in Week Three of this Riddle, quadriceps exercise are valuable. Julia went to a physical therapist who specializes in dancers and she performed the exercises religiously at home even after the appointments ended. As a result, she will be a stronger and better dancer in the long run. Here is Julia’s take on the whole episode:

“Of course I’m disappointed about the not being in the ‘Nutcracker’ this year, but I have no intention of giving up dancing! If anything, this problem with my knee has made me more passionate about ballet than ever. I read a quote from George Balanchine that goes ‘I don’t want people who want to dance I want people who have to dance.” That describes me perfectly! I’ll get through this and then ‘On with the dance’!”

Come back to ThirdAge.com next Thursday when we’ll introduce a new medical riddle!