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Osteochondritis Dissecans

Osteochondritis Dissecans

What is Osteochondritis Dissecans?

Osteochondritis dissecans (OCD) occurs when there is injury to cartilage within a joint. Cartilage is a tissue that lines the ends of bones; its primary purpose is to provide a smooth surface that decreases the friction where bones meet to form joints. It also helps to lessen the forces that go through joints.

The process leading to OCD begins when the blood supply to the layer of bone that lies directly under the cartilage layer drops. As a result, the bone does not receive the nutrients from blood that it needs to maintain its normal structure, and begins to die. This process is called avascular necrosis. When the health of the bone decreases, the cartilage does not have a good support system, and is susceptible to injury. If there is continued load applied to the joint (eg, repetitive walking, running, jumping, landing), the cartilage fragment may dislodge from the bone. When this occurs, it can lead to a cascade of symptoms, including pain, inflammation, and decreased function.

How Does it Feel?

Common signs and symptoms that develop with OCD include:

Swelling of the affected area following activity.
Restricted joint movement (range of motion).
Pain when moving the joint.
Tenderness to touch along the affected joint.
A feeling of “popping,” cracking, or grinding when moving the affected joint; pain, stiffness, or “locking” after sitting with the knee bent or straight for a prolonged period of time
Worsening pain during or following activity, particularly with walking, running, jumping, or changing direction. Children may complain of pain during recess or gym activities.
Typically, symptoms of OCD develop gradually as the damage to the cartilage and bone progresses. Sometimes, individuals do not recognize that they have OCD because they cannot remember a specific time or injury that caused their pain, or their initial symptoms are not enough to completely restrict their activity. This is especially common with children, who may not recognize that anything is wrong or be able to describe their symptoms. However, if untreated, the degree of OCD can progress and make treatment more difficult.

How Is It Diagnosed?

The first step to diagnosing OCD is to have a thorough clinical examination. Your physical therapist will ask about your medical history and activity regimen. Your physical therapist will perform a physical exam to measure the affected joint’s movement (range of motion), strength, mobility, and flexibility. You might also be asked to gently perform movements to provoke the pain you are experiencing. Younger children may require the help of a parent or guardian to detail their complaints and behavior changes in response to symptom development. The child’s teacher or athletic coach may also be able to provide information specific to how the child responds to certain physical activities during the school day.

The second step in the diagnosis process is the use of medical diagnostic imaging. Your physical therapist may refer you to a physician, who will order x-rays of your joint in a variety of positions to assess weight-bearing effects on it (eg, walking, standing). If more severe joint damage is suspected, an MRI or CT scan may be ordered to look more closely at the overall status of the joint and surrounding tissues.

Your medical team will grade the status of the affected bone and cartilage based on your MRI findings, and assign it a point on a scale. If surgery is required, an additional scale will be used to label the level of damage present. These scales will be helpful as your physical therapist develops an individualized rehabilitation program.

OCD may also occur in conjunction with other joint injuries. Therefore, it is important that the medical team use thorough diagnostic tests to ensure all injuries are identified as treatment plans are developed.

If you have joint pain that is not responding to rest, seek the advice of a medical provider! If you have joint paint that worsens and is not responding to rest, seek the advice of a medical provider!
How Can a Physical Therapist Help?
Your physical therapist will design an individualized treatment program specific to the nature of your condition and your goals. Your treatment may include:

Range of Motion Exercises. One of the most common symptoms of OCD is abnormal motion of the affected joint. Your therapist will assess your motion compared to expected normal motion, and the motion of the uninvolved joint on the other side of your body.

Muscle Strengthening. Strengthening the muscles around the injured joint is an essential part of the rehabilitation program. When there is an injury to a joint that causes pain and swelling, muscles often become inhibited, which means they may not function at their normal capacity. In the event of OCD, decreases in muscle performance may not be obvious at first, but may worsen as the degree of damage to the cartilage and bone progresses. For example, as the muscles along the front and back of the thigh (the quadriceps and hamstrings) cross the knee joint, they help control the motion and forces that are applied to the bones of the knee.

Strengthening the hip and core muscles can also help balance the amount of force on the joints of the leg, particularly during walking or running. Your physical therapist will assess these different muscle groups, compare the strength in each limb, and prescribe specific exercises to target your areas of weakness.

Manual Therapy. Physical therapists are trained in manual (hands-on) therapy. Your physical therapist will gently move and manipulate your muscles and joints to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own. In patients with OCD injuries, manual therapy techniques can help to restore the joint’s normal motion.

Modalities. Your physical therapist may recommend therapeutic modalities, such as ice and heat, to aid in pain management.

Bracing. Compressive sleeves placed around the affected joint may help reduce pain and swelling. In the event that surgery is required, braces may be used to control the amount of motion that is allowed as the postsurgical rehabilitation program progresses. For example, if an OCD injury at the knee joint is treated surgically, a brace will keep the knee straight for the first several weeks after surgery.

Activity Guidance. Since OCD may progress slowly over time, your physical therapist will use your symptoms as a guide to prescribe activity levels that will help and not harm your joint. Your therapist will consider the stage and extent of your OCD, and recommend a specific exercise program to address your needs and maximize the health of the affected joint. Consultation with your physician regarding periodic diagnostic imaging will help make sure that the cartilage and bone are ready to withstand certain loads.

Surgery Considerations.
When conservative management strategies are not successful in the treatment of OCD, or in cases where there are other associated injuries, surgery may be considered. The goal of surgical intervention is to restore the area of damaged cartilage and bone. There are many factors to consider when determining the appropriate surgical treatment, including the nature of your condition, your age, and your desired activity level. Your physical therapist will refer you to an orthopedic surgeon to discuss your surgical options.

Can this Injury or Condition be Prevented?

There are some factors that may influence the development of OCD, such as the size and shape of the bones, family genetics, and a child’s developmental stages, which physical therapy cannot address directly. However, there are numerous ways in which physical therapists may help decrease the risk of a young person developing OCD. To lessen the risk of developing OCD:

Avoid too much high-intensity exercise until a child is developmentally ready to handle high loads of exercise and activity.
Develop stretching and strengthening activities specific to a young athlete’s needs.
Make sure the athlete has “healthy shoes” (ie, sport-specific, not too old and worn down, a good match to the athlete’s foot type).
Allow adequate rest and recovery between athletic events.
Understand the common signs and symptoms that children may exhibit when they have a joint injury.
Educate young athletes on the risks of pushing through pain.

Real Life Experiences

Sam is a 13-year-old soccer player with 3 older brothers, and endless energy. When he’s not on the soccer field playing for his middle school and club teams, he’s playing pick-up sports with his brothers in the backyard.

One day at soccer practice, Sam got tackled and landed a bit awkwardly on his knee. A tough kid, he shook it off and kept playing. That night, he asked for ice, telling his parents that he was fine, but just felt like he had bruised his knee when he fell. That weekend, his team played in a 3-game tournament. As the team’s best defender, Sam barely spent any time on the bench. His knee felt sore by the end of the tournament, but he didn’t want to miss the annual Thanksgiving backyard “Turkey-Bowl,” so he didn’t mention it to his parents.

Several weeks later, Sam’s parents got a call from his soccer coach, who told them that Sam seemed to be limping and in pain when he ran, and when he planted his left leg to kick the ball. The school nurse also sent them an email reporting that Sam asked for ice during his lunch hour. Sam’s parents called their physical therapist, and took him in the next day.

Sam’s physical therapist asked him questions regarding his injury, how long he had been having symptoms, what activities seemed to bother him most, and what things made it feel better. She took several measurements, examining the range of motion in his knees, testing his strength, watching him walk and stand on 1 leg, and pressing gently on certain areas around his knee joint. Sam complained of some mild knee-locking and difficulty getting his knee completely straight when standing and lying down. Because many of these findings were abnormal and Sam was in pain, his physical therapist referred him to an orthopedic physician.

Sam’s physician ordered an MRI, which showed that his cartilage was bruised and inflamed. He told Sam’s parents there was some early damage to his cartilage, with some mild separation of the cartilage from the bone. He diagnosed OCD. Fortunately, the diagnosis was made early enough that surgery was not required. However, his physician explained that it would be important to develop a treatment plan to allow the cartilage to heal.

Sam was issued crutches, and had to use them to walk for several weeks to avoid stressing the cartilage in his knee. His physical therapy treatments began right away.

Sam’s physical therapist used different techniques, including manual (hands-on) therapy, stretching, icing, and gentle strengthening exercises for the muscles of the leg and hips to help decrease the swelling at his knee, and help him regain his range of motion and strength.

Once Sam no longer experienced symptoms, he was able to stop using crutches, and he began working on functional activities, like balance, squatting, and progressive strength exercises. Within a few weeks, Sam was back to running and jumping, and began practicing different soccer-specific activities.

At a follow-up appointment several months after his initial injury, the OCD had healed. Sam met the functional requirements to return to sports. He was very excited to get back on the soccer field. Sam’s physical therapist made sure he understood that it was crucial to let his coach and parents know if his knee started to bother him again.

Sam continued working on stretching and strengthening activities at home to make sure his knee stayed healthy. Not only did he earn back his starting position on the soccer team, he also showed his brothers that he was back stronger than ever for his family’s backyard football games!

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