, Stratford PW, Mayo N. Norkin
The literature does not yield conclusive evidence regarding the contribution of specific gene products to the development of a lesion. Children as young as nine or ten can develop this condition. Increasing strength with a focus on the lower extremity and core musculature serves as a stabilizing force to protect the joint and dampen forces around the joint.104 Balance activities are critical to restore normal proprioceptive feedback from the knee joint.126 Once full active range of motion and weight bearing are achieved, the patient is progressed to the advanced phase and should begin running and gradually proceed to impact and sport-specific activities, as tolerated.110, A recent systematic review identified a lack of consistency on the indications for operative treatment of JOCD lesions, with 40% of studies not providing clear indications and 60% recommending surgery after failure of nonoperative treatment.108 Proposed treatment algorithms, however, offer many recommendations.33,95 For stable JOCD lesions without loose bodies, 3 to 12 months of nonoperative treatment is recommended, followed by drilling if the lesion remains unhealed.33,124 Approximately 50% to 67% of JOCD lesions heal in 6 to 18 months with nonoperative treatment, and thus do not require surgery.17,18,100,124 For unstable or displaced lesions with salvageable fragments, fixation with or without drilling or microfracture is recommended. This classically occurs on the lateral aspect of the medial femoral condyle. Future studies to examine the effects of specific, nonsurgical interventions on adult patients with stable OCD lesions would be beneficial. 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 What Are the Signs & Symptoms of Osteochondritis Dissecans? . This usually happens due to the lack of blood supply to the area. , Beguiristain J, Krauspe R, et al. Abbreviation: OCD, osteochondritis dissecans. 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. 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. 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. Blood-flow Restriction Training for a Person With Primary Progressive Multiple Sclerosis: A Case Report, Enhanced Pronociceptive and Disrupted Antinociceptive Mechanisms in Nonspecific Chronic Neck Pain, The Journey of Recovery—Caregivers’ Perspectives From a Hip Fracture Telerehabilitation Clinical Trial, A Prospective Observational Study of Emergency Department–Initiated Physical Therapy for Acute Low Back Pain, Physical Therapist Roles During the Opioid Epidemic in Rural Appalachia: Preparing Students to Educate Communities, International Classification of Functioning, Disability and Health (ICF), Receive exclusive offers and updates from Oxford Academic, Marrow edema (diffuse or reticular high signal intensity), High-signal fluid or cyst(s) within fragment, Copyright © 2020 American Physical Therapy Association. The patient then was instructed in joint protection strategies to decrease loading across the right tibiofemoral joint.
The patient reported a change in her footwear and initiation of activity modification immediately after the initial physical therapy intervention. This may allow safe, progressive exercises for the quadriceps, hamstrings, and gastrocnemius with increasingly stronger resistance. J Orthop Sports Phys Ther 2014;44(9):665–679. 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). B
Over time, OCD lesions can lead to further degenerative changes in the elbow.
Screws, staples, or a screw-plate device are inserted across one side of a growth plate, which slows the growth under the device and allows full growth on the side of the knee that is opposite the device (FIGURE 14).74 This can gradually correct a varus or valgus knee deformity after only a few months if the patient is still growing. 49, No. . Modified heel slides (30°–90°) were used to promote pain relief and tissue healing through increased synovial fluid diffusion. Garrett
Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). This may result in separation and instability of a segment of cartilage and free movement of these osteochondral fragments within the joint space.That process can lead to pain, loose body formation and joint effusion. FP
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. It usually takes 3 months or longer to heal completely. JM
For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Is there a dose response for valgus unloader brace usage on knee pain, function, and muscle strength? In the elbow, the most common area affected is the capitellum, although it has been reported to affect the olecranon and the trochlea. The specific knee injury we are going to talk about is osteochondritis.. Tegner
, Nelson DW, Colville MR. Berndt
Familial osteochondritis dissecans: a dysplasia of articular cartilage? How does the condition develop? Walker
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. , Sluka KA. MH
If it heals completely, kids who have it usually don't have any long-lasting problems. 62, No. 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. Address correspondence to Dr Eric J. , Morris RL, Boeh SD, et al. RA
Osteochondritis dissecans (OCD) refers to a painful joint condition that involves damage to the cartilage and underlying bone within a joint. DJ
On radiographs, most JOCD lesions appear as a dark, bone-deficient area just beneath the cartilage surface.16,44 Due to their frequent posterior location, many JOCD lesions can only be visualized on a tunnel or notch-view radiograph. 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. , Whitehead R. Yoshida
Once your diagnostic examination is complete, the Physical Therapists at Rocky Mountain Therapy Services have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle. Studies have reported prescribing 4 to 12 weeks of non-weight bearing following osteochondral autologous transplants,37 microfracture,37 fixation,60,77,78 and transarticular drilling,128 and 6 to 12 weeks of partial or touch-down weight bearing for fixation118 and osteochondral allografts.76 Full range of motion has been allowed immediately following fixation and drilling procedures.77,78,128 Unloader braces have been recommended to help resume weight bearing and mobility, while protecting the knee from overload.92 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 Studies of adults with osteoarthritis suggest that a brace may decrease pain and improve strength and activity, but might not impact joint space or knee kinematics.42,52 The effectiveness of bracing and activity modification for knee JOCD has yet to be established.19,20 Furthermore, when considering forms of immobilization, health care providers should be cognizant of the findings from animal studies suggesting that long-term immobilization may have a negative impact on articular cartilage that may not be reversible.6,41, The goal of the initial phase of postoperative rehabilitation is to restore full range of motion, maintain quadriceps function, and reduce joint swelling, which can be achieved through passive range-of-motion exercises, straight leg raises, cryotherapy, and gradually advancing to the stationary bike and deep-water running.53 Continuous passive motion has also been recommended53 but is not often used following surgery.37,76,77 The decision to advance toward weight bearing should be made by the therapist and physician together and be based on reductions in pain, swelling, and stiffness as well as signs of radiographic healing. 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. A
This bone and cartilage can then break loose, causing pain and possibly hindering joint motion. MJ
The retroarticular technique, however, is more technically difficult than the transarticular technique and may raise the risk of incomplete JOCD drilling, overpenetration into the joint, or injury to soft tissue or saphenous nerve.40 The number of holes drilled is dependent on the size of the lesion.62 The most widely used operative treatments for stable JOCD lesions are retroarticular and transarticular drilling,1 which have a success rate of 75% to 100%.32,62 To improve healing, it has been proposed that the retroarticular drilling tunnels be filled with bone cells and bone-forming stem cells from iliac crest bone marrow that are percutaneously harvested from the patient's hip with a bone biopsy needle (FIGURES 13A and 13B).75 This procedure is indicated for lesions that are not mobile, incongruent, or displaceable and may help to stimulate healing of the JOCD lesion versus drilling alone and to avoid damage to the stable articular cartilage.75 The effectiveness of this technique has not been evaluated. 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. It can also affect other joints, such as elbows and ankles. The accuracy of the Dipaola et al30 staging system ranges from 30% to 83% for knee OCD when compared to arthroscopy, with lower accuracy for younger patients.30,48 Chen et al21 proposed another staging system using 3-D, T1-weighted, gradient-echo MRI in combination with routine MRI (TABLE) and found 83% to 90% agreement between MRI and arthroscopy. Anderson
, Nielsen DH, Soderberg GL. 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. Koenig
Anderson et al43 also hypothesized that increased cutaneous blood flow, resulting from high-current iontophoresis (1.5–4.0 mA), may aid clearance of DEX-P, resulting in lower penetration of the drug into subcutaneous tissues. A joint surface damaged by OCD doesn't heal naturally. .
A histologic and autoradiographic study in man, Magnetic resonance imaging of the knee in children and adolescents. 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). 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. Williams
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. A home exercise program was initiated to address the decreased muscle performance of the right lower extremity. Diagnosis of osteochondritis dissecans (OCD) is generally made during the history and physical examination. In some cases, you or your doctor will be able to feel a loose fragment inside your joint. 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. Discontinued given her 0/10 pain rating maintained over a 10-day period movement at the knee, elbow and.... Her early pain relief radiographic healing124 have also been used, Jacobson SC effect mechanism the. 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