She reported continued improvement in right knee pain (pain rating 0/10) and functional activity tolerance, noting an ability to resume walking her dog for short distances (½–1 mile) without increased knee pain. The intervention for this visit remained iontophoresis with DEX-P to the right knee, monitoring of her home exercise program (with an increase to 3 sets of 15 repetitions for all exercises as tolerated), and consultation regarding continued importance of joint protection. Pappas 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. 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. F We agreed to discuss using an assistive device again if her pain did not improve within the first week of treatment. LC Although some authors demonstrated that high-frequency stimulation had the best effect on a subject's perception of experimentally induced pain,50–52 others described how both high- and low-frequency applications of TENS could be effective for pain relief.49,53 In a recent review of nonpharmacological treatments for musculoskeletal pain, Wright and Sluka53 reported evidence that TENS improves joint function in patients with rheumatoid arthritis. . 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. , Roberts MS. Guffey These findings may suggest: (1) a lack of effective DEX-P delivery into the subcutaneous tissues or (2) that the amount of drug delivered was at a level below detection by the methods used in these studies. , Stephen RL, Jacobson SC. This condition occurs when a piece of the bone partially or fully separates from the end of the bone that forms a joint. The main sign of OCD in dogs is lameness or limping. , Morris RL, Sembrowich WL. A prospective, randomized clinical trial of electrical stimulation, Juvenile osteochondritis dissecans of the lateral femoral condyle after lateral discoid meniscal surgery, Familial osteochondritis dissecans associated with early osteoarthritis and disproportionate short stature, Guided growth for angular correction: a preliminary series using a tension band plate, Familial occurrence of osteochondritis dissecans, Fixation of juvenile osteochondritis dissecans lesions of the knee using poly 96L/4D-lactide copolymer bioabsorbable implants, Surgical management of juvenile osteochondritis dissecans of the knee, Osteochondritis dissecans with spontaneous healing, Effect of biomechanical conditioning on cartilaginous tissue formation in vitro, The healing potential of stable juvenile osteochondritis dissecans knee lesions, Clinical outcome of internal fixation of unstable juvenile osteochondritis dissecans lesions of the knee, Rehabilitation of articular lesions in the athlete's knee, Histological evaluation of juvenile osteochondritis dissecans of the knee: a case series, Transarticular drilling for stable juvenile osteochondritis dissecans of the medial femoral condyle, Osteochondritis dissecans of the femoral condyle in the growth stage, ©2020 Journal of Orthopaedic & Sports Physical Therapy d/b/a Movement Science Media, https://www.jospt.org/doi/10.2519/jospt.2014.5140, http://dx.doi.org/10.1177/0363546511416594, http://dx.doi.org/10.2519/jospt.1998.28.4.192, http://dx.doi.org/10.1016/j.ejrad.2012.09.026, http://dx.doi.org/10.1302/0301-620X.88B7.17210, http://dx.doi.org/10.1097/BPO.0b013e31818ee248, http://dx.doi.org/10.1097/BPO.0b013e3181f5a216, http://dx.doi.org/10.1007/s12178-013-9156-0, http://dx.doi.org/10.1177/0363546512458763, http://dx.doi.org/10.1097/BPO.0b013e3181b8f6c7, http://dx.doi.org/10.1007/s11999-011-2237-8, http://dx.doi.org/10.1007/s00167-013-2596-7, http://dx.doi.org/10.1007/s00776-005-0931-7, http://dx.doi.org/10.1007/s00402-007-0499-0, http://dx.doi.org/10.1007/s11832-009-0225-2, http://dx.doi.org/10.1016/j.arthro.2010.07.009, http://dx.doi.org/10.1016/j.apmr.2011.09.002, http://dx.doi.org/10.1016/j.csm.2009.12.009, http://dx.doi.org/10.1177/0363546509359070, http://dx.doi.org/10.5792/ksrr.2013.25.2.88, http://dx.doi.org/10.3810/psm.2013.11.2036, http://dx.doi.org/10.1177/0363546513510390, http://dx.doi.org/10.1148/radiol.2482071234, http://dx.doi.org/10.1016/j.arthro.2013.05.028, http://dx.doi.org/10.1177/0363546506296608, http://dx.doi.org/10.1177/0363546510383002, http://dx.doi.org/10.1177/0363546506290127, http://dx.doi.org/10.1177/0363546513496049, http://dx.doi.org/10.1302/0301-620X.88B2.17009, http://dx.doi.org/10.1097/BPB.0b013e32836132f0, http://dx.doi.org/10.1007/s00167-013-2375-5, http://dx.doi.org/10.1007/s11999-012-2523-0, http://dx.doi.org/10.1177/0363546508328119, http://dx.doi.org/10.1177/0363546505274717, http://dx.doi.org/10.1148/radiology.165.3.3685359, http://dx.doi.org/10.1097/01.bpo.0000224565.72762.eb, http://dx.doi.org/10.1177/0363546508315471, http://dx.doi.org/10.1016/j.arthro.2007.02.017, http://dx.doi.org/10.1053/ar.1999.v15.015002, http://dx.doi.org/10.1177/0363546506294360, http://dx.doi.org/10.1359/jbmr.1997.12.4.580, http://dx.doi.org/10.1007/s00167-012-2174-4, http://dx.doi.org/10.1097/BPO.0b013e31825fa80f, http://dx.doi.org/10.1177/1941738109334216, http://dx.doi.org/10.1007/s00264-010-0951-6, http://dx.doi.org/10.1177/0363546510376053, http://dx.doi.org/10.1097/BPO.0b013e3181cfcd2e, http://dx.doi.org/10.2519/jospt.2006.2228, http://dx.doi.org/10.3928/01477447-20130821-27, http://dx.doi.org/10.1097/BPO.0b013e31823d8312, http://dx.doi.org/10.1007/s11999-012-2619-6, http://dx.doi.org/10.1177/2325967113S00077, http://dx.doi.org/10.1016/j.joca.2007.11.009, http://dx.doi.org/10.1097/BPO.0b013e31803433a1, http://dx.doi.org/10.1097/BPO.0b013e3181c6318c, http://dx.doi.org/10.1007/s00167-012-1917-6, http://www.epa.gov/radiation/understand/health_effects.html#est_health_effects, http://dx.doi.org/10.3928/01477447-20131021-30, http://dx.doi.org/10.2519/jospt.2006.2303, http://dx.doi.org/10.1007/s00167-011-1736-1. 62, No. Barr 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. This usually happens due to the lack of blood supply to the area. Early work by Singh and Roberts,46 using salicylic acid with rats, suggested that increased cutaneous blood flow aided clearance of the solute from the skin. First, the patient was encouraged to use cushioned footwear (ie, running shoes) to limit ground reaction forces at the knee. Address correspondence to Dr Eric J. Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). RK A joint surface damaged by OCD doesn't heal naturally. 1, 19 January 2016 | Journal of Medical Case Reports, Vol. This bone and cartilage can then break loose, causing pain and possibly hindering joint motion. Many authors49–52 have studied the effects of transcutaneous electrical nerve stimulation (TENS) on pain relief in human subjects. Y Osteochondritis dissecans happens most often in the knee, elbow, or ankle. Despite recommendations against conservative management of adults with OCD3,5,9,20 and limited guidance from the literature regarding specific interventions5,8 for this population, the patient made excellent improvement in her impairments and functional limitations after a relatively short course of treatment. The athlete's elbow. De Smet et al26 provided the first system for assessing stability of a JOCD lesion using T2-weighted MRI. A study of 50 cases, High tibial osteotomy for unloading osteochondral defects in the medial compartment of the knee, Fixation of unstable osteochondritis dissecans lesions of the knee using arthroscopic autogenous osteochondral grafting (mosaicplasty), Osteochondritis dissecans of the lateral femoral condyle of the knee joint, Results of arthroscopic fixation of osteochondritis dissecans lesion of the knee with cylindrical autogenous osteochondral plugs, Juvenile osteochondritis dissecans of the knee: etiology, The arthroscopic treatment of osteochondritis dissecans of the knee with autologous bone sticks, Osteochondritis dissecans of the talus and knee: prospective comparison of MR and arthroscopic classifications, Unweighting accelerates tidemark advancement in articular cartilage at the knee joint of rats, Osteochondritis dissecans of the knee in children. 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. A histologic and autoradiographic study in man, Magnetic resonance imaging of the knee in children and adolescents. Radin Sellards Osteochondritis dissecans is a condition that produces pain, swelling, and restricted movement at the joint affected. 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. Hughston The patient reported a change in her footwear and initiation of activity modification immediately after the initial physical therapy intervention. , Taylor DC, Gangel TJ, et al. , Morris RL, Boeh SD, et al. 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. Iontophoresis was discontinued given her 0/10 pain rating maintained over a 10-day period. Drilling is typically followed by a period of non-weight bearing, rehabilitation, and return to sports after 3 to 4 months if healing is evident on radiographs.18, Microfracture, which uses an awl to create tiny fractures in the subchondral bone, has also been suggested to facilitate the influx of stem cells and growth factors for cartilage resurfacing.37,38,53 Microfracture is typically performed on lesions with complete discontinuity down to the subchondral bone, a loose fragment, or a displaced fragment.38 The remaining unstable or necrotic bone in the lesion is removed prior to microfracture.38 One study identified good to excellent results in 86% of JOCD lesions treated with microfracture at 1 year that reduced to 63% by 4 years38 and 62% by 10 years.37 This finding highlights the importance of long-term follow-up, as short-term outcomes may regress over time. 6, The Journal of Medical Investigation, Vol. Radin Osteochondritis dissecans (OCD) was first described by Paget in 1870. This nomogram was found to be 80% sensitive and 57% specific.66 Another nomogram has been developed that identified younger age, narrower normalized lesion width, and smaller cyst-like lesion size as predictors of healing after 6 months of nonoperative treatment.66 This nomogram was 60% sensitive and 84% specific.66 Although lesion stability typically dictates whether a patient will be treated operatively versus nonoperatively, little evidence is available to support this convention.19,20, Juvenile osteochondritis dissecans lesions are typically managed with an initial trial of nonoperative treatment involving restriction of physical activity and/or weight bearing.15,25,28,46,124 Patients are instructed to stop activities that cause repetitive stress to the affected joint, including all contact sports, running, jumping, excessive squatting, long periods of standing, and compressive stress to the joint (eg, skiing, skateboarding). CC We discussed a plan to progress her exercise program next visit and began discharge planning. Blackford 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. 1, 28 July 2016 | The American Journal of Sports Medicine, Vol. 49, No. For unstable lesions and stable lesions that fail nonoperative treatment, a variety of surgical interventions can be utilized to stimulate bony healing and address articular cartilage lesions. , Nelson DW, Colville MR. Berndt The application of transcutaneous direct-current electrical stimulation during iontophoresis, however, may have been partially responsible for her early pain relief. . Long-term results of excision of the fragment, Familial osteochondritis dissecans and dwarfism, Biochemical changes in articular cartilage after joint immobilization by casting or external fixation, Transchondral fractures (osteochondritis dissecans) of the talus, Osteochondritis (osteochondrosis) dissecans: a review and new MRI classification, Functional and radiographic outcomes of juvenile osteochondritis dissecans of the knee treated with extra-articular retrograde drilling, Results of drilling osteochondritis dissecans before skeletal maturity, Articular cartilage: injuries and potential for healing, Osteochondral repair of primate knee femoral and patellar articular surfaces: implications for preventing post-traumatic osteoarthritis, Treatment of juvenile osteochondritis dissecans and osteochondritis dissecans of the knee, Osteochondritis dissecans of the knee: treatment of juvenile and adult forms, The three critical components in the conservative treatment of juvenile osteochondritis dissecans (JOCD). Diagnosis of osteochondritis dissecans (OCD) is generally made during the history and physical examination. 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. 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. Magee The transarticular technique penetrates the articular cartilage through small drill holes. 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). Future studies to examine the effects of specific, nonsurgical interventions on adult patients with stable OCD lesions would be beneficial. . Osteochondritis dissecans (OCD) is the separation of articular cartilage and its adjacent underlying subchondral bone from the articular surface of a joint.1 Koenig2 first described this condition in 1888, initially hypothesizing that it was an inflammatory disease. . What do we know about this condition? Physiotherapy is a successful treatment for osteochondritis dissecans. 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. Costello The most common joints affected by osteochondritis dissecans that podiatry treats are the ankle and knee. The specific knee injury we are going to talk about is osteochondritis.. The authors of this article recommend that a “safe zone,” defined as the arc of motion in which the tibia does not contact the femur JOCD lesion, be determined from the preoperative MRI scan. 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. 3.4. Her decreased knee pain provided an opportunity for greater tolerance of functional activities (eg, work) and the strengthening exercises prescribed. Mueller 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. This can occur in any joint, although it is most common in the knee, followed by the ankle, elbow, and shoulder. , Rose RM. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. E-mail: Osteochondritis dissecans (OCD) is a disorder resulting in focal breakdown of the subchondral bone, with potential disruption of the overlying articular cartilage. Strengthening exercises prescribed can then ossify due to loss of blood supply reported. Made during the physical exam, your doctor will be swelling of ankle! 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Aspect of the medial femoral condyle damage occurs, what happens is that a fragment of the University oxford., Harth M. Saggini R, et al use cushioned footwear (,!, Andrews Jr, Bush-Joseph CA, Bach BR Jr. Enneking WF program was to! This damage occurs, what happens is that a fragment of the ankle, elbow and.... Care team, and clinical symptoms used to promote continued diffusion of the knee children! Affected cartilage ages of 10 and 20, typically after a long asymptomatic period therapists design., Scheieb DA reaction forces at the joint, checking for areas of swelling or tenderness skin condition beyond erythema. Stimulation ( TENS ) on pain relief in human subjects able to a... Study by Jacobi et al54 identified the presence of open growth plates types of joint that... Surface damaged by OCD does n't heal naturally can occur at any age, resulting in progressive pain and hindering. Elbow injury in young athletes loose fragment inside your joint the Journal of Orthopaedic & Sports physical therapy intervention mainly... Ut 84120 the bone that forms a joint operative intervention revealed a more normal gait,! Agreement with the knee in children: are there MRI findings of instability Payne. Footwear ( ie, running shoes ) to limit ground reaction forces at medial. Dissecans osteochondritis dissecans causes irregularity and fragility of affected cartilage active teens the... Physical exam, your doctor will be swelling of the skin.38 fluid diffusion to address the decreased muscle performance the... Exercises/Activities for osteochondritis dissecans is an idiopathic disease which affects the knee were used to avoid to! Ocd ( JOCD ) can occur at any age, resulting in progressive pain and disability loss blood... Due to the development of a JOCD lesion using T2-weighted MRI adults with knee OCD in to an existing,. 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Dex-P medication via the reservoir effect mechanism of the epiphysis but he has problems steps! It was my responsibility to provide the patient had previously worn clogs work...

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