Modified heel slides (30°–90°) were used to promote pain relief and tissue healing through increased synovial fluid diffusion. 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. 62, No. Although commonly used for diagnosis, plain radiographs are not recommended for classification of JOCD lesions. De Smet et al26 provided the first system for assessing stability of a JOCD lesion using T2-weighted MRI. Osteochondritis dissecans (OCD) was first described by Paget in 1870. 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. . . , Nielsen DH, Soderberg GL. . Walker , McCreary EK, Provance PG. Damage to the secondary growth plate could then disrupt new bone production. 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. Treating Osteochondritis Dissecans of the Ankle in Milwaukee Understanding OCD Ankle Lesions & How to Heal. Radin . It is not self-limiting or in other words, it doesn't get better on its own. A comparison of MRI and arthroscopic findings, Osteochondritis dissecans of the knee in identical twins: a report of two cases, Is valgus unloader bracing effective in normally aligned individuals: implications for post-surgical protocols following cartilage restoration procedures, On the production of some of the loose bodies in joints, The reliability to determine “healing” in osteochondritis dissecans from radiographic assessment, Surgical treatment options for osteochondritis dissecans of the knee, Viability of loose body fragments in osteochondritis dissecans of the knee. , White DJ. A joint surface damaged by OCD doesn't heal naturally. As a result, it is possible for portions of cartilage to become lodged within the joint, leading to limitation in motion. F 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. I am back with another exercise and injury interview for you and today it focuses on a knee injury. Osteochondritis Dissecans of the knee is an obtained, reversible, idiopathic condition of the subchondral bone of our body and the leg. In some cases, you or your doctor will be able to feel a loose fragment inside your joint. 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. CR JC 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. 1, 19 January 2016 | Journal of Medical Case Reports, Vol. SH Vitamin D Deficiency: The Missing Etiological Factor in the Development of Juvenile Osteochondrosis Dissecans? 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). 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. S Signs of Osteochondritis Dissecans in Dogs . Modified straight-leg-raising exercises were performed with the knee held in approximately 30 degrees of flexion. These exercises included modified wall slides (20°–90°) and modified active knee extension (90°–20°) in an effort to promote improved strength and endurance in knee extension through a greater ROM while still avoiding excessive loading to the OCD lesion. , Nelson DW, Colville MR. Berndt , Mayo MF, Gabaree CL, et al. Osteochondritis dissecans is a condition during which parts of the joint cartilage and subchondral bone (bone under the cartilage) is separated from the remaining bone. This case illustrates the combination of current best evidence and the patient's individual needs and expectations from physical therapy when making clinical decisions about care. Radiographs are most often used to evaluate JOCD lesion healing.4,17,18,32,47,60,62,76,87,100,124 However, a few studies have used MRI.29,66,78,83,85,118,125 Success rates have ranged from 50% to 67% for nonoperative treatment,17,18,100,124 75% to 100% for retroarticular and transarticular drilling,32,62 75% to 100% for fixation,29,60,78,118,125 62% to 86% for microfracture,37,38 83% to 100% for osteochondral autograft/allograft plugs,37,38,76,83,85,87 82% for autologous chondrocyte implantation,67 and 25% to 53% for fragment excision.4,47 Although these studies used radiographs and MRI, the accuracy and reliability of these modalities have not been compared, and a valid and standardized measure for determining JOCD healing has not been established. The patient progressed well throughout her course of physical therapy. , Rose RM. 44, No. This can occur in any joint, although it is most common in the knee, followed by the ankle, elbow, and shoulder. , Roberts MS. Guffey . , Hamel L, Behnke P. Hasson 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. Osteochondritis dissecans is an idiopathic disease which affects the subchondral bone and its overlying articular cartilage due to loss of blood flow. 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. Many authors49–52 have studied the effects of transcutaneous electrical nerve stimulation (TENS) on pain relief in human subjects. Osteochondritis dissecans occurs especially in young athletes involves in throwing sports such as baseball or field athletic events like javelin. During the physical exam, your doctor will press on the affected joint, checking for areas of swelling or tenderness. She reported only mild tenderness along the anteromedial femoral condyle on the right knee (pain rating 4/10) with direct palpation to the area. The active electrode was then resecured with tape and the patient was instructed to leave it in place for 8 to 12 hours as tolerated. The patient missed a visit and returned for her fifth and final visit 10 days after the fourth visit. The athlete's elbow. First, the patient was encouraged to use cushioned footwear (ie, running shoes) to limit ground reaction forces at the knee. Mueller Incomplete restoration of immobilization induced softening of young beagle knee articular cartilage after 50-week remobilization, Bracing improves clinical outcomes but does not affect the medial knee joint space in osteoarthritic patients during gait, Effect of low loading and joint immobilization for spontaneous repair of osteochondral defect in the knees of weightless (tail suspension) rats, Diagnosis of osteochondritis dissecans of the femoral condyles: the value of the lateral x-ray view, Bilateral osteochondritis dissecans of the lateral femoral condyle following bilateral total removal of lateral discoid meniscus: a case report, Juvenile osteochondritis of femoral condyles: treatment with transchondral drilling. 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. Due to a lack of evidence on its early diagnosis, optimal treatment, and long-term course of healing, JOCD presents a unique challenge for the health care team. This bone and cartilage can then break loose, causing pain and possibly hindering joint motion. Osteochondritis dissecans (OCD) of the elbow doesn't occur in immature throwing athletes very often so there isn't a lot of information about it to help guide treatment. A home exercise program was initiated to address the decreased muscle performance of the right lower extremity. Her decreased knee pain provided an opportunity for greater tolerance of functional activities (eg, work) and the strengthening exercises prescribed. This work was presented, in part, at the Annual Conference of the Pennsylvania Physical Therapy Association, October 26–28, 2001, Seven Springs, Pa, and at the Combined Sections Meeting of the American Physical Therapy Association, February 20–23, 2002, Boston, Mass. 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. The interventions, other than iontophoresis, utilized with this patient were based on clinical decisions that used the formula stress=force/area as their foundation.30 Interventions were chosen primarily in an effort to decrease the amount of force applied to the tibiofemoral joint (ie, change in footwear, avoidance of knee extension during first week of treatment, patient education regarding modification of standing time at work, effects of increased body weight and strengthening exercises for muscles crossing the joint). , Henderson GH, Daniels JC, Scheieb DA. 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 application of transcutaneous direct-current electrical stimulation during iontophoresis, however, may have been partially responsible for her early pain relief. Osteochondritis dissecans (OCD or OD) is a joint disorder primarily of the subchondral bone in which cracks form in the articular cartilage and the underlying subchondral bone. 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. 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. Information obtained from the clinical examination and diagnostic image findings should be used together to determine those adult patients with OCD who may benefit from physical therapist management. . 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. 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. A histologic and autoradiographic study in man, Magnetic resonance imaging of the knee in children and adolescents. , Rutherford MJ, Payne W, Phillips C. Glass 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. 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. B J Orthop Sports Phys Ther 2014;44(9):665–679. Failure to establish a familial background, Familial multiple osteochondritis dissecans. In: Altchek DW, Andrews JR, eds. . Which form loose bodies within the joint. A clinical survey, Osteochondritis dissecans of the femoral condyles. min. 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. Unfortunately, the patient did not complete a follow-up MRI, which had been scheduled 1 year after the initial MRI; therefore, no comparative imaging was available to assess healing of the lesion. 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. 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 exercises included modified heel slides and modified straight-leg-raising exercises. It occurs more often in males. 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. FP Best Exercises/Activities For Osteochondritis Dissecans Osteochondritis Dissecans imply a health condition, which develops in the bone joints. MJ 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. 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. The transarticular technique penetrates the articular cartilage through small drill holes. , Lowe AS, McCormack K, et al. 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. 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). How does the condition develop? This case report focused on the physical therapist management of an adult (>20 years) female patient with OCD of the right knee. Her right knee pain, at worst, had decreased by 50% (5/10 versus 10/10) by the second visit, it was rated as 0/10 to 1/10 (on average) by the fourth visit, and she experienced no pain with any functional activities at discharge. . . . Your comment will be reviewed and published at the journal's discretion. 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). Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? Children as young as nine or ten can develop this condition. Later, a lack of evidence for the presence of an inflammatory process in the region of the articular lesion led Pappas3 to name the condition “osteochondrosis dissecans.” Although some authors4 support this nomenclature, the term “osteochon… Therefore, I believe that physical therapists' decisions regarding how to manage adult patients who have a diagnosed osteochondritic lesion of the knee, including the selection of specific physical therapy interventions, should be made in light of several factors: (1) the disease process, (2) patient characteristics (eg, age, health status), (3) clinical examination findings, (4) diagnostic imaging results, (5) physician consultation, and (6) the patient's goals for therapy. Studied the effects of transcutaneous electrical nerve stimulation ( TENS ) on pain relief in subjects. Therapy, 18 April 2020 | Skeletal Radiology, Vol re-examination was performed a. Gait pattern, with minimal pain noted during either the right lower at! 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