BBD We suggest the use of safe zones as a means of protection for the healing tissue. Osteochondritis Dissecans of the knee is an obtained, reversible, idiopathic condition of the subchondral bone of our body and the leg. These authors, along with Ulett et al,49 also reported on the effectiveness of both high- and low-frequency TENS (ie, electroacupuncture) to inhibit pain through centrally mediated responses in animals and human subjects. JM 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. Which form loose bodies within the joint. Juvenile Osteochondritis Dissecans. B Philadelphia, PA: Lippincott Williams & Wilkins; 2001:231-248. Osteochondritis dissecans (OCD) refers to a painful joint condition that involves damage to the cartilage and underlying bone within a joint. Damage to the secondary growth plate could then disrupt new bone production. It is recommended that rehabilitation of JOCD be tailored to the individual patient, based on the stage and radiographic status of the lesion and the mode of surgery employed when surgically addressed. Some studies define healing as radiographic union of the JOCD lesion with the underlying bone and/or clinical resolution of symptoms.60,118 Classifying JOCD healing based on a single follow-up radiograph has been found to have fair reliability (interrater kappa of 0.44, intrarater kappa of 0.68).94 To improve reliability, it has been suggested that the percentage of healing be evaluated across a series of radiographs.32 Unfortunately, slight differences in the radiographic technique used at each visit can lead to a false positive impression of healing. Diagnosis of osteochondritis dissecans (OCD) is generally made during the history and physical examination. Walsh Classification of osteochondritis dissecans of the capitellum Difelice GS, Meunier MJ, Paletta GA Jr. Elbow injury in the adolescent athlete. 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. The 4 signs of instability include (1) a focal osteochondral defect filled with joint fluid, (2) an articular fracture, (3) an adjacent fluid-filled subchondral cyst of 5 mm or greater in diameter, and (4) a line of high signal intensity between the lesion and underlying bone.26 Some authors suggest that the high-signal line may indicate that synovial fluid has seeped under the lesion through a break in the surface cartilage,30,79,88,90 whereas others suggest that the line may represent vascular granulation and healing of the fibrovascular tissue.8,129 This line of high signal intensity may not always correlate with instability on arthroscopy, perhaps because arthroscopy cannot visualize a nonarticular deep separation between the lesion and the underlying bone (FIGURE 6).90 Using the De Smet et al26 classification system, MRI has been found to have a sensitivity of 100%, but a specificity ranging from only 11% to 15%.48,58 Hefti et al47 and Dipaola et al30 have also developed MRI staging systems (TABLE). Journal of Orthopaedic & Sports Physical Therapy, 18 April 2020 | Skeletal Radiology, Vol. Although there is a growing body of literature on this condition, the etiology and optimal methods for treatment, rehabilitation, and evaluating outcomes remain inconclusive due to a lack of quality evidence. , Nho SJ, Cole BJ. EL DJ Her muscle strength was rated as “Normal” for both the right knee flexors and extensors, although she did describe “fatigue” in the right lower extremity after a full day of work (8 hours). 39, No. , Rose RM. Osteochondritis dissecans affects joints, most frequently the knee, in children and adolescents. Pappas 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. A histologic and autoradiographic study in man, Magnetic resonance imaging of the knee in children and adolescents. , Harty M. De Smet Tegner 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. JD No funding was obtained for this commentary. These parameters, although not identical to other forms of TENS commonly used to achieve analgesia, are similar to low-frequency electroacupuncture (2 Hz, 30 minutes).49 It appears reasonable, therefore, to suggest that her early decreases in pain may have been aided, in part, by the current application from the phoresor unit during treatment application. Federico Iontophoresis was delivered to the anteromedial, right knee of my patient through direct-current (low-rate) stimulation for a period of 20 to 25 minutes per treatment session. A staging system has been developed by Berndt and Harty7 (TABLE), but, when evaluated, plain radiographs were incorrectly staged for all but 1 medial femoral condyle lesion when compared to arthroscopy.30 Furthermore, plain radiographs do not adequately show disruptions in the articular cartilage or whether the lesion is attached to the underlying bone for accurate staging.90 While not optimal for staging, radiographs are used extensively to assess healing progression. Gudeman Over time, OCD lesions can lead to further degenerative changes in the elbow. Physician, parent, and child, 99m-Technetium phosphate compound joint scintigraphy in the management of juvenile osteochondritis dissecans of the femoral condyles, The results of conservative management of juvenile osteochondritis dissecans using joint scintigraphy. Osteochondritis dissecans occurs especially in young athletes involves in throwing sports such as baseball or field athletic events like javelin. . During the initial phase, striving for a normal range of motion, equal to the contralateral side, is beneficial for healing and is accomplished through passive range-of-motion exercises and stretching.104 Although controversial, basic science studies suggest that the use of controlled range-of-motion exercises, either through a continuous passive motion device or repetitive active assisted range of motion, may help to nourish the articular cartilage surface and promote a healthy knee joint.11,56,59,104 Once full passive range of motion and partial weight bearing are achieved, the patient can be progressed to the intermediate phase, with active range-of-motion exercises, muscle strengthening, and balance training.126 Neuromuscular electrical stimulation of the quadriceps muscles113 and weight-bearing and non-weight-bearing activities or progressive resistive exercises126 can facilitate muscle strengthening. A comprehensive classification system for JOCD that incorporates information from radiographs, MRI, arthroscopy, and clinical evaluation has yet to be validated, but various methods have been employed to characterize the size, severity, and stability of JOCD lesions. P Malalignment of the lower limb intuitively makes sense in the context of mechanical-axis deviation, as a change in the forces through the joint would increase strain on specific aspects of the joint. Valgus alignment was associated with lateral condyle lesions, whereas varus alignment was associated with medial condyle lesions, although the amount of valgus/varus remained within normal physiological ranges.54 This increased loading on the affected knee compartment may have implications for the use of an unloader brace. JC Address correspondence to Dr Eric J. No abnormalities in the skin condition beyond mild erythema were noted. F FP The specific knee injury we are going to talk about is osteochondritis.. , Ilahi OA, Graf BK. Smutok . For unstable lesions, and those stable lesions that fail to heal with nonoperative treatment, a variety of surgical interventions are utilized, with healing success rates of 62% or greater for all treatments except fragment excision.4,29,32,37,38,47,60,62,67,76,78,83,85,87,118,125 Research on nonoperative and postoperative rehabilitation is currently limited and insufficient for evidence-based recommendations. Oxford University Press is a department of the University of Oxford. On MRI, healing has been defined by an absence of a sclerotic rim at the interface between the osteochondral fragment and subchondral bone.29,78,102 Magnetic resonance imaging, however, is more expensive than radiographs, and a biopsy requires a second surgery. Byl As a result, it is possible for portions of cartilage to become lodged within the joint, leading to limitation in motion. Osteochondritis dissecans occurs most often in children and adolescents. Dipaola DM Costello Our institutional guidelines,110 which were formulated based on experience, consensus, and the literature for related knee conditions, have established baseline criteria for pain and effusion, weight bearing, range of motion, muscle performance, and neuromuscular control to determine when to advance a patient to greater weight bearing. 10, No. Drilling juvenile osteochondritis dissecans: retro- or transarticular? In addition, Paterno et al97 reported a high incidence of second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and identified altered movement patterns as predictive factors for second injury. Her home exercise program was modified to include strengthening exercises for the muscles about the hip, knee, and ankle that required movement of the tibiofemoral joint. Limited quality evidence is available on the level of agreement between MRI and arthroscopy for the diagnosis of knee JOCD,101 with 1 study indicating a moderate level of agreement (κ = 0.70)73 that improved with the addition of information on the medical history, clinical exam, and plain radiographs (κ = 0.90).73. Best Exercises/Activities For Osteochondritis Dissecans Osteochondritis Dissecans imply a health condition, which develops in the bone joints. 49, No. Pain and effusion can be managed with cryotherapy105 and electrical stimulation.113, Patients may also be immobilized for 4 to 16 weeks to alleviate pain and mechanical symptoms and to allow the knee to rest from repetitive stress to the joint surface.4,36,66,124 Immobilization may include partial weight bearing in a cylinder or long-leg cast,124 a hinged brace,92,124 and/or the use of crutches or other ambulatory aids.15,66 Some studies suggest serial casting every 4 to 6 weeks until healing is evident on radiographs.124 Evidence is currently unavailable as to which approach is best. 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. Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). Familial osteochondritis dissecans: a dysplasia of articular cartilage? . Osteochondritis dissecans happens most often in the knee, elbow, or ankle. 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. . The problem is common among adolescents and children. In the elbow, the most common area affected is the capitellum, although it has been reported to affect the olecranon and the trochlea. Williams Rehabilitation following microfracture for chondral injury in the knee, Association between mechanical axis of the leg and osteochondritis dissecans of the knee: radiographic study on 103 knees, Bilateral osteochondritis dissecans of the femoral condyles in both knees: a report of two sibling cases. If it heals completely, kids who have it usually don't have any long-lasting problems. A home exercise program was initiated to address the decreased muscle performance of the right lower extremity. Nordin . Juvenile Osteochondritis Dissecans: Cartilage T2 Mapping of Stable Medial Femoral Condyle Lesions, Osteochondritis Dissecans: Pathoanatomy, Classification, and Advances in Biologic Surgical Treatment, Focal Defects of the Knee Articular Surface: Evidence of a Regenerative Potential Pattern in Osteochondritis Dissecans and Degenerative Lesions, Direct comparison of different surgical approaches in a woman with bilateral osteochondrosis dissecans of her knees: a case report, Repetitive Stresses Generate Osteochondral Lesions in Skeletally Immature Rabbits, Intact Bone Vitality and Increased Accumulation of Nonmineralized Bone Matrix in Biopsy Specimens of Juvenile Osteochondritis Dissecans, State-of-the-art ultrasonographic findings in lower extremity sports injuries, Nondisplaced fragment that is completely detached, Completely detached and displaced fragment, Classification using magnetic resonance imaging, Small signal change; fragment not clearly outlined, Partially visible fluid between fragment and bone, Articular cartilage thickening; low signal changes, Articular cartilage breached; low signal rim behind fragment, Articular cartilage breached; high signal rim behind fragment, Classification using gradient-echo magnetic resonance imaging, Intact overlying cartilage; no demarcated interface, Low-signal fragment-donor interface; partial cartilage tear, High-signal fragment-donor interface; partial or complete cartilage tear, Low- or intermediate-signal fragment-donor interface; decreased signal line through overlying articular cartilage, Irregularity and softening of articular cartilage; no fragment, Articular cartilage breached; not displaceable, definable fragment, Articular cartilage breached; attached but displaceable fragment. The patient progressed well throughout her course of physical therapy. This may allow safe, progressive exercises for the quadriceps, hamstrings, and gastrocnemius with increasingly stronger resistance. The patient, however, was reluctant to use an assistive device and decided instead to initiate the first 2 strategies. Third, I discussed the benefit of using an assistive device (ie, straight cane) to provide unloading of the right tibiofemoral joint. , Henderson GH, Daniels JC, Scheieb DA. Many validated measures have been used in recent years to assess the functional outcomes of patients with knee JOCD and the effectiveness of treatment.119 The most common questionnaires are the International Knee Documentation Committee Subjective Knee Evaluation Form,4,51,60,78,125 the International Cartilage Repair Society scale,37,38,67,78,125 the Hughston Clinic Knee Questionnaire,4 the Lysholm knee score,9,60,78,128 the Knee injury and Osteoarthritis Outcome Score,77,95 the Tegner activity scale,9,37,60,125 and the Marx activity scale.77 There is now a validated pediatric version of the International Knee Documentation Committee Subjective Knee Evaluation Form available for clinicians and researchers as well.63 In addition to evaluating surgical treatments, these questionnaires may be helpful tools for physical therapists to evaluate patients as they progress through rehabilitation and to compare the effectiveness of different approaches. A study by Jacobi et al54 identified the presence of mechanical-axis deviation in both adolescents and adults with knee OCD. 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. Patients with a history of increased athletic participation also demonstrated decreased healing rates of OCD lesions.8 Hefti and colleagues8 suggested that this may have been the result of tissue or lesion overload. Sellards 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. Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis. A clinical survey, Osteochondritis dissecans of the femoral condyles. OCD usually causes pain during and after sports. For some athletes, this may be an opportunity to supplement their lifestyle with nonimpact activities or to work on fundamentals of their sport that do not require impact (eg, free-throw shooting in basketball). 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. Iontophoresis was discontinued given her 0/10 pain rating maintained over a 10-day period. E-mail: Osteochondritis dissecans (OCD) is a disorder resulting in focal breakdown of the subchondral bone, with potential disruption of the overlying articular cartilage. 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. After the 6 months his pain was gone, which was a blessing, however, he still has issues with function. , Hamel L, Behnke P. Hasson For unsalvageable fragments, immediate operative treatment is recommended, but the technique varies based on lesion size and demand.33 Although these recommendations have been made, the literature is currently inconclusive on the comparative effectiveness of treatment for JOCD.1,19,20,119, The goal of arthroscopic drilling is to increase revascularization and reossification of the JOCD lesion to facilitate bone healing.4,10,13,46 The surgeon can drill the JOCD lesion directly through the surface cartilage (transarticular technique) or indirectly from behind the joint surface (retroarticular technique).40 Both drilling techniques are minimally invasive and create bone tunnels into the lesion using a Kirschner wire or a drill bit. Although little direct evidence that this effect exists in humans, it is credible to suggest that using thermal modalities before or after iontophoresis may diminish the reservoir of medication in the skin available for diffusion to deeper tissues. 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. Osteochondritis dissecans (OCD) describes an injury to the area of bone just under the cartilage surface, an area called the subchondral bone. At the time I treated this patient, there were discrepancies in the literature and among the clinical pharmacy staff at my facility regarding use of the anode or the cathode as the active electrode with DEX-P. Based on current evidence, however, my facility has been using the cathode consistently as the active electrode when providing iontophoresis of DEX-P for the past 4 years. She, however, was still working an 8-hour shift (versus a 12-hour shift before injury) and had not yet resumed her regular walking program. The cause of Osteochondritis Dissecans is currently not known to the medical world but if not cured in time OCD can … M 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. Several validated outcome questionnaires exist for children with knee conditions and may be useful tools for health care professionals to evaluate, compare, and advance the different treatment and rehabilitation approaches to JOCD. 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. 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. 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. Future studies to examine the effects of specific, nonsurgical interventions on adult patients with stable OCD lesions would be beneficial. Physical therapists mainly design the following treatment programs consists of exercises and activities according to the nature of your underlying condition. She received physical therapy intervention that included iontophoresis with DEX-P, strengthening and ROM exercises that were modified to limit stress to the lesion, and patient education on joint protection strategies. Aichroth Approximately 50% to 67% of stable JOCD lesions heal successfully with nonoperative treatment. Report of a kindred, Role of magnetic resonance imaging and clinical criteria in predicting successful nonoperative treatment of osteochondritis dissecans in children, The clinical utility and diagnostic performance of MRI for identification and classification of knee osteochondritis dissecans, Juvenile osteochondritis dissecans of the knee: perifocal sclerotic rim as a prognostic factor of healing, Subsequent injury patterns in girls' high school sports, Current concepts in the rehabilitation following articular cartilage repair procedures in the knee, Effects of cryotherapy on arthrogenic muscle inhibition using an experimental model of knee swelling, Matching osteochondritis dissecans lesions in identical twin brothers, Vascular foramina and arterial supply of the distal end of the femur, Indications for surgical management of osteochondritis dissecans of the knee in the pediatric population: a systematic review, Juvenile osteochondritis dissecans of the knee: predictors of lesion stability, Osteochondritis dissecans knee histology studies have variable findings and theories of etiology, A predictive factor in osteochondritis dissecans: a radiographic analysis, Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. These lesions are located within the intercondylar notch of the femur (non–weight bearing surface) and thus are subject to less loading over time. Common Osteochondritis Dissecans Lesion Classification Systems, Magnetic resonance imaging is much more accurate and useful than radiographs for classifying the stability of JOCD knee lesions. , Morris RL, Sembrowich WL. Is there a dose response for valgus unloader brace usage on knee pain, function, and muscle strength? Anderson We agreed to discuss using an assistive device again if her pain did not improve within the first week of treatment. How does the condition develop? A joint surface damaged by OCD doesn't heal naturally. 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. Osteochondritis dissecans (OCD) can occur at any age, typically after a twisting injury of the ankle. OCD is defined as “a fragment of articular cartilage together with subchondral bone that has become separated partly or completely from a joint surface”. , Tuite MJ, De Smet AA. At the 9-month follow-up (from initial examination), the patient reported “good” right knee function (95% SANE score) with all activities and no pain (0/10). What do we know about this condition? MJ De Smet et al26 provided the first system for assessing stability of a JOCD lesion using T2-weighted MRI. Management Strategies for Osteochondritis Dissecans of the Knee in the Skeletally Immature Athlete, Surgical management of osteochondritis dissecans of the knee in the paediatric population: a systematic review addressing surgical techniques, Arthroscopic drilling in juvenile osteochondritis dissecans of the medial femoral condyle, Osteochondritis dissecans of the knee. 62, No. The patient had previously worn clogs at work, which had a firm sole and minimal foot control through the upper shoe. RA In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. The second and third visits included application of iontophoresis (as described previously), review of the home exercise program, and continued monitoring of right knee symptoms and joint protection strategies. Signs of Osteochondritis Dissecans in Dogs . If the patient has completed growth, then the bone can be cut and realigned with a metal plate or an external fixator, which is a much more invasive procedure than guided growth in the growing patient.82, There are few evidence-based recommendations in the literature for postoperative rehabilitation following surgical interventions for JOCD lesions of the knee. OCD can mean one or more flakes of articular cartilage have become separated. 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.