P3A363: When It Is More Than Knee Pain, and It Is Multiple Sclerosis

Introduction: Pediatric onset multiple sclerosis is a rare condition. Approximately 3-5% of all individuals diagnosed with MS will experience disease onset before 16 years of age. It is crucial for clinicians caring for athletes to keep a broad differential diagnosis in mind and to be knowledgeable about this condition.

Case Description: 15 year old F initially presents to PCP with R knee pain x 1 month. No specific injury or trauma. She also has numbness and tingling in R foot and R calf on and off. At time of presentation to PCP she was very active with her dogs and her school basketball team. No other complaints of pain or joint abnormality. No fever, no night pain, no popping, no clicking. She also lost 40 pounds unintentionally in the last 3 years. She was then sent to PT and Sports Medicine for further evaluation. When seen by Sports Medicine one month later she was noted to have a significantly changed exam.

Her physical exam revealed :
Musculoskeletal:
- Normal appearance of bilateral lower extremities, no atrophy
- FROM knees bilaterally
- FROM of hips bilaterally
- 5/5 strength bilateral LE
- Negative SLR
- Negative Lachman, Anterior and Posterior drawer, & McMurray testing.
- Tenderness to Palpation along Distal 1/3rd R Tibia

Neurologic:
- Positive wide-based unsteady gait, unable to stand independently
- Positive brisk knee and ankle jerk reflexes bilaterally
- Positive Babinski reflexes bilaterally
- Positive Romberg: falling forward with eyes closed
- Great difficulty standing. Needs to hold on to the wall and her father in order to take a step or stand.
- Numbness and tingling endorsed when palpated R anterior tibia.

To further assess MRI of the Brain was obtained. MRI showed numerous supratentorial and infratentorial white matter lesions. A diagnosis of multiple sclerosis was made and she was admitted directly to the inpatient neurology for further management.

Discussion: With all joint pain in athletes a broad differential including musculoskeletal disorders/injuries, vascular abnormalities, neurologic abnormalities or infectious causes should be kept in mind when evaluating patients.

Multiple sclerosis in children has a relapsing-remitting disease course. Acute relapses are new neurologic deficits lasting greater than 24 hours, without illness. Most pediatric patients with multiple sclerosis recover well from acute relapses. Poor recovery from an attack, a higher recurrence of attacks, and attacks involving the brainstem have a greater possibility of future disability.

Conclusion: Through this case, clinicians may gain a heightened awareness of an uncommon initial presentation of a central nervous disorder in an adolescent athlete. Early diagnosis and treatment may slow down the disease activity and prevent long term disability.