Refer for imaging

This week during my rural placement in outpatient department, I had a 13 years old girl coming for new assessment. She has had bilateral knee pain for 2 years, with right knee worse than the left. She has seen her GP previously and was thought to have growing pain. On recent visit to GP, PF pain syndrome was considered as there was pain to inferior to patella, and hence was referred to see a physio for further opinion and management.

During my subjective assessment, all symptoms and signs almost fit with PFJ problem. Her aggravating factor included running, long distance running and squatting. Her pain came on spontaneous and slowly getting worse over the 2 years. She also mentioned that she used to jump onto her knees a lot with her brother when she was younger for one year. However, it was long before onset of her knee pain. Her objective assessment did not help me clear things up at all. Her alignment was good and no apparent swelling or atrophy. She was TOP all around the patella area, no particular spots are worse and also TOP in muscle bulks of squats, hamstring and adductors. In AROM, She was slightly short of full flexion limited by pain. Her patellar glides are all painful, most painful and tight medially. Pain with resisted knee flexion, extension, hip flexion and adduction. She is able to do full squats however very painful. McConnell did not ease pain with resisted knee extension. I was very confused with what her diagnosis could be. So I called in my supervisor to help me with this particular patient. And he re-assessed a few objective signs and also unable to pinpoint the structure involved. Fortunately, her mother booked a xray for her the day after. So I asked her to come back after the xray. I gave her hot packs and HEP of stretches, strengthening ex’s, hot packs and also tubigrip for support.

The day after, they came back with the x-ray. She almost is having an avulsion fracture of tibial tuberosity of her R knee, and also similar problem but better with her L knee. Therefore I happily diagnosed her with bilateral Osgood-Oshlatters. However, if the mother has not yet planned to do the X-ray, I wonder if I would immediately ask her to get a xray of the knee. With her history of no trauma, insidious onset and no clear pain pattern, I may not have referred her to x-ray immediately. This occasion will be an alarm bell for me. If there’s possible yellow flags, it would be safer to get a x-ray to clear. Has anyone else had similar experience or other comments?