Osteochondritis Dissecans

Risk: The condition usually presents itself when an individual is between 10 and 30 years of age, but can present itself at any age (Jacobs). Osteochondritis dissecans affects men more frequently than women; the knee is affected 2 to 3 times more often in men than in women (Jacobs). Those individuals who frequently participate in strenuous sports, or perform repetitive activities that put the joint under stress, are at an increased risk of developing osteochondritis dissecans. Athletes in baseball, gymnastics, wrestling, tennis, weight lifting, cheer leading, football, golf, shot put, and shooting are at an increased risk of developing osteochondritis dissecans of the elbow.

Incidence and Prevalence: The exact prevalence of OCD is unknown, but based on joint-specific studies, OCD affecting the femoral condyle in individuals under the age of 50 is estimated to occur in 6 out of 10,000 men and 3 out of 10,000 women (Bui-Mansfield). Between 30% and 40% of individuals affected by osteochondritis dissecans have the condition in the corresponding joint as well (bilateral) (Jacobs).

History: The individual may complain of gradually worsening pain in one or more joints (arthralgia). Pain worsens with movement of the joint(s) and is usually relieved by rest. A grating and grinding sensation (crepitus) caused by joint movement may be reported. He or she may report that the affected joint periodically becomes locked or that joint movement is limited. The individual with an affected knee may also report a catching or giving way on bending or straightening the knee (as when going up and down stairs). Some individuals may not have any symptoms at all.

Physical exam: Exam findings may be minimal. Bending the joint would be painful. Complete joint extension may not be possible. Minor joint swelling (effusion) may be present. The affected joint might be tender to touch. There may be evidence of muscle wasting (atrophy) due to disuse of the affected joint. Sometimes, a loose fragment may be felt. If there is knee involvement, the individual may have a positive Wilson's sign, when pain is elicited with knee extension and internal rotation. The chief physical finding is the presence of crepitus upon movement of the joint. The individual with an affected knee may walk with his or her foot turned outward (externally rotated) in an effort to relieve pain.

Tests: X-rays are used to diagnose osteochondritis dissecans. Routine back and front (anteroposterior) and side (lateral) views, as well as a tunnel (intercondylar) view (knee), if applicable, are usually taken. Visualization of the joint by arthrography can identify surface irregularities and, if the imaging dye is found in the cartilage surface, can identify a detached fragment. MRI is frequently used instead of an arthrogram. CT scan, bone scan, and arthroscopy may also be performed, but are not necessary for diagnosis. These imaging techniques are more useful in predicting prognosis, and for determining management for a given case. Ultrasound imaging is also used in some cases because scanning can be done in combination with motion to determine degree of stability of articular cartilage and presence of loose intra-articular fragments. Arthroscopic examination is sometimes used to stage (grade) the progress of osteochondral lesions but results agree with radiographic staging in 56% of cases (Bui-Mansfield).

The type of rehabilitation for osteochondritis dissecans depends on the specific joint affected. In general, therapy aims at restoring normal flexibility and strength, as well as decreasing pain. These aims may be achieved through the use of modalities, such as heat and cold (Braddom), as well as stretching and strengthening exercises. After the acute or postoperative period, it is common to initiate physical therapy with a heat treatment, to relax the tissues around the joint and conclude with a cold treatment, to control the pain and swelling that may follow exercise. Rehabilitation will vary depending on whether the individual has had surgery, or has plans for surgery (Bradley; Jurgensen).

Initially therapy focuses on reducing symptoms and promoting independence in daily activities. If the lower extremity is involved, gait training with an assistive device, such as a cane or walker, may be necessary for independent ambulation, with weight bearing as indicated by the physician. Assistive devices may be needed to promote independent use of the upper extremities.

Rehabilitation then focuses on restoring motion and strength. If the condition has been managed nonoperatively, full range of motion may be difficult to achieve, and the joint may lock intermittently throughout the available range. Postoperatively, full range of motion should be expected. Exercise may be progressed based on the recommendations of the physician. It may be beneficial to instruct the individual in general exercises for the adjacent joints to prevent loss of strength and motion.

Range of motion exercises may help to restore full mobility to the joint. Therapy should progress to strengthening exercises as tolerated, introducing all exercises slowly, so as to avoid trauma to the affected joint. Therapy should include flexibility exercises throughout the period of strengthening because, while strong muscles around the joint are critical, flexibility of the same muscle groups must be maintained. It is important to emphasize closed chain exercises, in which the foot is stabilized, as well as open chain exercises, in which the foot is free to move. During this phase, the therapist may instruct individuals in a home exercise program to be performed independently.

When full, pain-free motion is regained and the individual has sufficient strength for all activities of daily living, therapy may progress to balance and proprioceptive exercises. The difficulty of these exercises will be determined by the physician, individual, and therapist.

Prior to discharge from therapy, individuals should understand the need for continued exercise to maintain the stability of the joints, and should be taught ways to protect the joint during work and leisure activities. The individual's physician must determine the desired degree of joint loading prior to the individual's return to work and leisure activities.

Additional information may provide insight into the rehabilitation needs of these individuals (Canale).