Referred Knee Pain and Slipped Capital Femoral Epiphysis
A 12-year-old boy is referred for 4 weeks of right knee pain and a limp. He has obesity, no trauma, and pain that worsens with activity and improves with rest. He points to the medial knee. Examination shows limited internal rotation of the right hip, pain at the end range, and an antalgic gait. He has been treated with ice and stretching by a physical therapist without improvement. The family asks whether he can return to basketball after a few more weeks of therapy. Radiographs of the knee were reported as normal.
1. What is the likely diagnosis, and what are your next steps and urgency?
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Slipped capital femoral epiphysis must be excluded despite normal knee radiographs, because hip pathology refers pain to the knee. Obtain urgent anteroposterior and frog-leg lateral pelvis radiographs and make him non–weight-bearing. If radiographs are equivocal, obtain MRI or CT rather than continuing therapy. Consult orthopedics the same day. Delay risks further slip and avascular necrosis. Do not reassure the family that this is a knee sprain or a growth-related pain until the hip has been imaged and evaluated.
2. Describe the postoperative rehabilitation plan and return-to-activity considerations.
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After surgical stabilization, follow orthopedic weight-bearing restrictions. Begin protected range of motion, strengthening of the hip abductors and extensors, and gait training. Avoid forceful hip extension, rotation, and aggressive stretching early. Return to sport depends on healing, pain, strength, and orthopedic clearance, often 3–6 months; basketball carries pivoting and contact risk. Monitor the contralateral hip and educate the family about new pain. Coordinate school physical education restrictions and a gradual conditioning program.
3. How would you counsel the family about the contralateral hip, obesity, and long-term surveillance?
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Explain that the other hip is at risk and that new groin, thigh, or knee pain requires prompt evaluation. Discuss whether prophylactic pinning is recommended by orthopedics based on age and risk. Address obesity with a nonjudgmental, family-based nutrition and activity plan, because it affects healing and future joint health. Emphasize adherence to weight-bearing restrictions and follow-up. Arrange long-term hip surveillance and school accommodations. The goal is to prevent a second slip and early osteoarthritis, not just to return to basketball.