The incidence of OCD and its long-term effect on the knee joint are controversial. These exercises were chosen to strengthen the 2-joint muscles that cross the hip and knee joints, to allow for improved load attenuation by these muscles (ie, rectus femoris, hamstring group, gracilis, and tensor fasciae latae/iliotibial band).28 The decision to perform these exercises with the knee fixed in 30 degrees of flexion was an effort to protect the OCD lesion from further loading while initiating strengthening exercises on day 1 of her intervention. Osteochondritis Dissecans of the knee is an obtained, reversible, idiopathic condition of the subchondral bone of our body and the leg. Standard anteroposterior and lateral radiographs are often insufficient to diagnose JOCD lesions and often do not illustrate articular cartilage injuries, small lesions, or lesions of the patellofemoral joint (FIGURE 3).17,31,47,123 Unless a loose body is seen, radiographs do not show whether the surface cartilage of the JOCD lesion is stable or unstable, which is critical in treatment decision making. MH As a result, decreased stress on the chondral lesion might have helped diminish pain and future tissue damage.54, Careful loading (stress) of the lesion must be considered in light of its potential effects on tissue healing. NN Its role in clinical decision-making, Guided growth for the treatment of limb length discrepancy: a comparative study of the three most commonly used surgical techniques, Retro-articular drilling and bone grafting of juvenile knee osteochondritis dissecans: a technical description. A histologic and autoradiographic study in man, Magnetic resonance imaging of the knee in children and adolescents. BBD Although a centrally mediated analgesic effect from the electrical stimulation remains a plausible explanation for her early symptom relief, at the 9-month follow-up she said that she believed the change in footwear had the greatest overall influence on the successful resolution of her knee pain. Nonspecific knee pain is the most common early symptom, reported by 80% of individuals with JOCD.15 Although not as common, other possible symptoms include effusion (fluid in the joint), catching, locking, giving way, muscle atrophy, increased sensitivity, and specific tenderness.15,64,123 The potential presence of JOCD is camouflaged among the many benign juvenile knee-pain conditions, such as jumper's knee, the Osgood-Schlatter condition, and patellofemoral pain syndrome. Singh Vitamin D Deficiency: The Missing Etiological Factor in the Development of Juvenile Osteochondrosis Dissecans? Walker I am going to talk with Zach Moore who is a strength coach and he is going to talk about how he overcame numerous knee surgeries and osteochondritis. But the disease behaves much differently in children and for this reason is given a separate name, juvenile osteochondritis dissecans (JOCD), meaning osteochondritis dissecans of children. Osteochondritis dissecans (os-tee-o-kon-DRY-tis DIS-uh-kanz) is a joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. MA Is there a dose response for valgus unloader brace usage on knee pain, function, and muscle strength? This can occur in any joint, although it is most common in the knee, followed by the ankle, elbow, and shoulder. If the OCD lesion is smaller than 1 cm in diameter, it may be removed and the bed perforated with a drill or a pick to stimulate repair cartilage in-growth.4,35 Fragment excision, however, has been reported to have a relatively low success rate (25%–53%), along with an increased risk of osteoarthritis.4,47 Larger lesions that are irreparable can also be reconstructed with osteochondral autograft/allograft plugs (83%–100% success rate)37,38,76,83,85,87 or autologous chondrocyte implantation (82% success rate)67,80 (FIGURES 13A and 13B). The patient progressed well throughout her course of physical therapy. Analysis of 40 cases, Osteochondritis dissecans: a multicenter study of the European Pediatric Orthopedic Society, Correlation of magnetic resonance imaging to arthroscopic findings of stability in juvenile osteochondritis dissecans, Cartilage atrophy in the knees of patients after seven weeks of partial load bearing, Radiation dosimetry for extremity radiographs, Osteochondritis dissecans of the femoral condyles. Pellecchia Recent studies44,45 have shown an absence of DEX-P in the synovium and local venous blood after the application of iontophoresis delivered at a 4.0-mA current. This usually happens due to the lack of blood supply to the area. DJ Kendall The demographics and epidemiology of osteochondritis dissecans of the knee in children and adolescents, Juvenile versus adult osteochondritis dissecans of the knee: appropriate MR imaging criteria for instability, The basic science of continuous passive motion in promoting knee health: a systematic review of studies in a rabbit model, Internal fixation of juvenile osteochondritis dissecans lesions of the knee, Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents, Functional and radiographic outcome of juvenile osteochondritis dissecans of the knee treated with transarticular arthroscopic drilling, Reliability, validity, and responsiveness of a modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders, Management of osteochondritis dissecans of the knee: current concepts review. The previous injury to the medial ligament of the elbow may also result in this injury as it causes an increase angle and loading of the capitellum. Suggested Therapeutic Exercise • Gait drills: forward and backward march walk, soldier walk, side step, step overs, hurdle walk • Double leg balance drills - balance board, tandem balance However, these small drill holes in the articular cartilage may not heal even a year later.40 By drilling from behind the cartilage, the retroarticular technique (FIGURE 12A) avoids making small holes through the articular cartilage surface. Muscles have been described as “shock absorbers”54 because muscular contraction has the ability to protect cartilage.40 The ability to effectively engage in a strengthening exercise program, therefore, was necessary. The comparative effectiveness of treatments for JOCD also remains unknown due to a lack of well-controlled studies.1 Furthermore, clinical practice guidelines still need to be established regarding proper treatment of JOCD lesions based on relative size, location, stability of the lesion on magnetic resonance imaging (MRI), patient age, and status of growth plates.19,20. This classically occurs on the lateral aspect of the medial femoral condyle. In particular, I made a conscious decision to avoid correction of her gait deviations (limited knee extension, stance time and heel-strike on the right) during this early stage of treatment. Arthroscopy is the gold standard for assessing the status of the joint's surface cartilage, including the shape, strength, continuity, fissuring, softening, and detachment of the JOCD lesion (FIGURE 5). 39, No. Rauh et al103 reported that prior injury was a primary risk factor for future injury in young athletes. Does operative fixation of an osteochondritis dissecans loose body result in healing and long-term maintenance of knee function? Hughston Drilling juvenile osteochondritis dissecans: retro- or transarticular? , Scudds RA, Heck CS, Harth M. Saggini We suggest the use of safe zones as a means of protection for the healing tissue. Osteochondritis dissecans occurs when a fragment of bone or cartilage breaks away and falls into the joint space. WF This bone and cartilage can then break loose, causing pain and possibly hindering joint motion. , Han S, Han JS. Woolf Treating Osteochondritis Dissecans of the Ankle in Milwaukee Understanding OCD Ankle Lesions & How to Heal. The femoral condyles of the knee are the most common locations for OCD, and the incidence of OCD appears to be increasing among active children. A hinged brace that stabilizes and aligns the knee in valgus can shift the stress off the medial compartment, whereas a hinged brace that aligns the knee in varus can shift the stress off the lateral compartment (FIGURE 11).92,124 Preliminary evidence in healthy adults suggests that valgus unloader braces may be effective at realigning the knee and decreasing adduction while walking in patients with medial compartment pathology.92 Allowing for some weight bearing and passive motion has been shown to improve articular cartilage repair in animal studies,12,43 as cartilage may become more vulnerable after complete immobilization.49,89 Specific guidelines for the duration of immobilization and the extent of allowed range of motion and weight bearing have not been established.19,20, No widely accepted or validated rehabilitation protocol exists for patients with JOCD. B The transarticular technique penetrates the articular cartilage through small drill holes. , Jeske AH. Osteochondritis dissecans is an idiopathic disease which affects the subchondral bone and its overlying articular cartilage due to loss of blood flow. , Morris RL, Boeh SD, et al. DJ EL Classification of osteochondritis dissecans of the capitellum Difelice GS, Meunier MJ, Paletta GA Jr. Elbow injury in the adolescent athlete. JS Ischemia, the loss of blood flow, was proposed as an etiological factor by Paget93 in 1870, who described JOCD as a “quiet necrosis.” It was speculated that a loss of blood supply to the affected area may inhibit the tissue's ability to effectively re-form bone, resulting in cell death and separation of the bone from the cartilage.36,51 It has also been proposed that OCD lesions may be filled with fibro-cartilage resulting from deficient vascularization.72 The many authors who have investigated the possibility of lesion development due to ischemia have found little supporting evidence.3,4,23,107 However, some supporting evidence exists, including the ability to revascularize a partially attached lesion81 and the presence of osteonecrosis in most histology studies (7/10).111 Conversely, other studies have found a rich blood supply and no cell death in lesions of the medial femoral condyle.3,4,23,107 Authors of a recent study on the viability of detached osteochondral fragments from 5 patients reported that 88% of chondrocytes (the cells found in cartilage) were viable, compared to 92% of chondrocytes in the healthy native cartilage.96 This perhaps suggests that either OCD lesions are not a product of ischemia or the synovial fluid provides enough nutrition for the cells to remain viable.96 Despite this controversy, the ischemia hypothesis has generated many current treatments for OCD, including drilling to produce revascularization for improved blood flow into the lesion.9,95. It is also recommended that return to sports activity be based on whether the patient demonstrates healing on radiographs or MRI and has full range of motion and agility, near full strength, and no pain or limp. , Nielsen DH, Soderberg GL. When this damage occurs, what happens is that a fragment of the cartilage comes loose from the bone. , Zoppi M, Vecchiet F, et al. Lingering pain after an ankle sprain or a feeling your ankle is “stuck” or “catching” can be a sign of a bone chip in the ankle. Magnetic resonance imaging also enhances the visibility of bone cysts, subarticular high-signal lines, and articular cartilage fissures that may affect prognosis and treatment.30 For identifying JOCD knee lesions, MRI has been found to have a sensitivity ranging from 78% to 100%, a specificity ranging from 95% to 100%, and an accuracy of 100%.61,73 These findings for MRI are similar to those for radiographs and physical examination combined.61 Typically, all 3 methods are used for diagnosis and to make treatment decisions. Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? It is often difficult for patients to comply with these recommendations.15 For this reason, it is beneficial for the physician and therapist to offer alternative forms of exercise. GN , Rose RM. Healing predictors of stable juvenile osteochondritis dissecans knee lesions after 6 and 12 months of nonoperative treatment, Collagen-covered autologous chondrocyte implantation for osteochondritis dissecans of the knee: two- to seven-year results, Physeal widening in the knee due to stress injury in child athletes. Anderson Mueller In: Altchek DW, Andrews JR, eds. Irrgang It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Most experts agree that diagnosis and treatment of JOCD at an early stage are optimal for healing.15,18,24,64 Unfortunately, most patients are diagnosed with JOCD a year or more after the onset of symptoms.15,123,124 This delay in diagnosis is largely due to the nonspecific nature of the early symptoms and the nonspecific findings on physical exam. It was my responsibility to provide the patient with information that may help to limit further future injury to her knee. LC , Hamel L, Behnke P. Hasson She demonstrated no observable gait deviations during ambulation, noted the ability to walk her dog for ½ to 1 mile without difficulty, and reported a 95% rating of function (SANE score). She had been working 12-hour shifts consistently for more than 6 months and was able to walk down the aisle at her own wedding without difficulty wearing high-heeled shoes. The patient then was instructed in joint protection strategies to decrease loading across the right tibiofemoral joint. 49, No. Continuous passive motion following cartilage surgery: does a common protocol exist? It occurs more often in males. SD Search for other works by this author on: Osteochondritis dissecans of the knee: a historical review of etiology and treatment, Osteochondritis dissecans: a multicenter study of the European Pediatric Orthopedic Society, “Dem bones”: osteochondral injuries of the knee, The incidence of osteochondritis dissecans in the condyles of the femur, Osteochondritis dissecans of the knee: a clinical survey, Osteochondritis dissecans of the femoral condyles, Treatment of juvenile osteochondritis dissecans and osteochondritis dissecans of the knee, Characterizing osteochondral lesions by magnetic resonance imaging, Transchondral fractures (osteochondritis dissecans) of the talus, Reassessment of the MR criteria for stability of osteochondritis dissecans in the knee and ankle, Rehabilitation following surgical procedures to address articular cartilage lesions in the knee, Osteochondritis dissecans of the femoral condyle in the growth stage, Untreated osteochondritis dissecans of the femoral condyles: prediction of patient outcome using radiographic and MR findings, Comparison of the single assessment numeric evaluation method and the Lysholm score, Rating systems in the evaluation of knee ligament injuries, Assessing global pain severity by self-report in clinical and health services research, Measurement of Joint Motion: A Guide to Goniometry, Muscles, Testing and Function: With Posture and Pain, Basic Biomechanics of the Musculoskeletal System, Pathomechanics and classification of cartilage lesions, facilitation of repair, Treatment of plantar fasciitis by iontophoresis of 0, The efficacy of dexamethasone iontophoresis for the treatment of rheumatoid arthritic knees: a pilot study, Comparison of electromotive drug administration with ketorolac or with placebo in patients with pain from rheumatic disease: a double-masked study, Treatment of infrapatellar tendinitis: a combination of modalities and tranverse friction massage versus iontophoresis, Exercise training and dexamethasone iontophoresis in rheumatoid arthritis: a case study, The use of ultrasound as an enhancer for transcutaneous drug delivery: phonophoresis, Iontophoresis: applications in transdermal medication delivery, Mechanical factors in the aetiology of osteoarthritis, Role of muscles in protecting athletes from injury, Quantification of total dexamethasone phosphate delivery by iontophoresis, International Journal of Pharmaceutical Compounding, Effects of iontophoresis current magnitude and duration on dexamethasone deposition and localized drug retention, Iontophoresis of dexamethosone-phosphate into the equine tibiotarsal joint, Failure to detect dexamethasone phosphate in the local venous blood postcathodic iontophoresis in humans, Effects of vasoconstriction on dermal pharmacokinetics and local tissue distribution of compounds, Skin pH changes associated with iontophoresis, The quantity and distribution of radiolabeled dexamethasone delivered to tissue by iontophoresis, Electroacupuncture: mechanisms and clinical application, Transcutaneous electrical nerve stimulation: effect on peripheral nerve conduction, mechanical pain threshold, and tactile threshold in humans, Transcutaneous electrical nerve stimulation and the reaction to experimental pain in human subjects, Transcutaneous electrical nerve stimulation characteristics for altering pain perception, Nonpharmacological treatments for musculoskeletal pain, Tissue adaptation to physical stress: a proposed “Physical Stress Theory” to guide physical therapist practice, education, and research, Osteochondritis dissecans of the femoral condyles: a long-term follow-up study, © 2005 American Physical Therapy Association. . The diagnostic accuracy of the combination of radiographs with medical history and physical examination has been found to have a sensitivity of 77% and specificity of 98%.61. Approximately 50% to 67% of stable JOCD lesions heal successfully with nonoperative treatment. Single-plane hip flexion (in a supine position), extension (in a prone position), abduction (in a left side-lying position), and adduction (in a right side-lying position) were performed within full available hip ROM for 2 sets of 10 repetitions each. Given the rapid change in her right knee pain at that time, I concluded that the need to consider using an assistive device was no longer warranted. Although the patient's work status continued with a limited 8-hour shift, she reported no pain throughout the work day and was planning to resume her normal 12-hour shift within the 2 weeks following discharge from physical therapy. OCD most commonly occurs in individuals between the ages of 10 and 20, typically affecting males more than females. The dosage was consistent with that recommended by Costello and Jeske.39 Upon completion of the iontophoresis, the skin under the active and dispersive electrodes was examined for any abnormal reactions to the direct current stimulation. Iontophoresis was discontinued given her 0/10 pain rating maintained over a 10-day period. On the fourth visit, 11 days after her initial visit, the patient reported minimal, intermittent right knee pain (0–1/10) and increased tolerance of all activities. Repetitive stress, especially in young athletes, is one of the most accepted causes of JOCD.14,47,51,64,123 A majority of patients with OCD (55%–60%) are regularly involved in sports,3,47 and repetitive cyclical stress through an athlete's joint may lead to chondral injury and possible vascular damage, leading to ischemia.14 Laor et al68,69 hypothesized that JOCD lesions could result from repetitive stress to the growth plate of the secondary ossification center that resides just between the surface cartilage and its supporting bone in the epiphysis of a growing athlete (FIGURE 2). Smutok , Mayo MF, Gabaree CL, et al. Although widely accepted, there is minimal research evidence to support repetitive trauma as the cause. GA Modified heel slides (30°–90°) were used to promote pain relief and tissue healing through increased synovial fluid diffusion. , Hergenroeder PT, Courtenay BG. Evidence suggests that the articular cartilage response to stress is dependent on delivering the appropriate amount of tissue loading.32,54 Hefti et al8 and Aichroth11 both found that the “classic” medial femoral condyle lesions demonstrated the least evidence of healing over time. An animal study, however, found that microfracture created dense bone compaction around the fractured holes and osteocyte necrosis that might have impeded repair, whereas drilling cleanly removed the bone and created channels for bone marrow influx without signs of necrosis.22. The healing process for JOCD can be frustratingly slow for all parties involved; however, premature return to activity can be devastating. Damage to the secondary growth plate could then disrupt new bone production. . Given the unloading effect that these actions may have had on the tibiofemoral joint, it appears that her early and continued decreases in pain may have been aided, in large part, by a decrease in the overall force placed on the lesion. , Stephen RL, Jacobson SC. , Lysholm J. If the physician/therapist is allowing weight bearing, athletes may be able to stay in shape by seeking other forms of exercise, including swimming, deep-water running, stationary bike, or elliptical machine.34,53,66,104 A basic science study suggests that shearing forces, such as those produced by the stationary bike and elliptical, may facilitate articular cartilage healing better than compressive forces.122 However, there is no available evidence on the effectiveness of these forms of exercise for JOCD. Modified straight-leg-raising exercises were performed with the knee held in approximately 30 degrees of flexion. The patient missed a visit and returned for her fifth and final visit 10 days after the fourth visit. The incidence of osteochondritis dissecans in the condyles of the femur, Osteochondritis dissecans of the femoral condyles: a long-term follow-up study, Osteochondritis dissecans. , Nelson DW, Colville MR. Berndt Varus and valgus malalignment of the knee has been reported in patients with medial and lateral condyle JOCD lesions, respectively.54 If the patient is skeletally immature, guided growth is a minimally invasive, minimally painful procedure to realign the knee.116 Guided growth can harness the power of the growth plate to correct the knee deformity. This case report focused on the physical therapist management of an adult (>20 years) female patient with OCD of the right knee. CC Upon discharge, ROM at the right tibiofemoral joint remained within normal limits, and no pain was noted with passive end-range flexion or extension overpressure to the joint. Therefore, clinical diagnosis currently relies on plain radiographs and MRI.123, Radiographs are useful to visualize subchondral involvement of a JOCD lesion in the femoral condyle; however, the sensitivity and specificity of radiographs for diagnosis have never been evaluated. The incidence of JOCD has increased in children under age 10 in recent years, with a large percentage involved in sports.3,47,57,70 The development of a universal classification system that aids in prognosis and treatment decision making is paramount to the proper treatment of this condition. Osteochondritis Dissecans Treatment Options for a PT (2, 3) • Rest, Physical Activity Modification to Limitation of Weight Bearing • Postural/Functional Training • ROM exercises (see videos 14a, 14b & 16 for hip/groin/knee) • Stretching (see videos 31 & 28 for hip/groin/knee) Koenig . She reported minor “fatigue” in the right lower extremity at the end of her 8-hour workday. 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