Ms Dann is from the Division of Athletics, Dr Mazerolle is from the Department of Kinesiology, Dr Denegar is from the Department of Physical Therapy, Dr Anderson is from the Division of Athletics, and Ms Sanger is from the University of Connecticut, Storrs; Mr Shannon is from Moore, Wilton; Dr Joyce is from Orthopaedic Sports Specialists, Glastonbury, Conn.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Catie Dann, MS, ATC, CSCS, Division of Athletics, University of Connecticut, 2095 Hillside Road, U-3078, Storrs, CT 06269; e-mail: Catie.firstname.lastname@example.org.
Osteochondritis dissecans (OCD) is a disorder involving necrosis of the subchondral bone that affects areas including the talar dome, head of the talus, the capitellum of the humerus, and the femoral condyles.1,2 The condition most commonly affects active adolescents, particularly boys, who are three times more likely to incur the condition than girls.1,2 The medial femoral condyle, due to its size and assumption of weight bearing during activity, is involved in 75% of all cases of OCD.1,2 The condition is found bilaterally in 20% to 30% of cases.1–3 Genetic predisposition to OCD may exist2; however, the condition is often a result of a multitude of interrelated elements,4 including but not limited to repetitive shear and compressive forces, abnormal ossification, and ischemia.1,4
Osteochondritis dissecans often occurs secondary to anterior cruciate ligament rupture.5–7 Classic presentation of an OCD includes a subtle onset of nonspecific symptoms,8 which include sensations of catching or locking, that is accompanied by generalized aching along the joint line and recurrent joint effusion.1,9,10 In addition, patients may exhibit subjective symptoms of activity-related pain and stiffness or diffuse pain after periods of inactivity.1 Restriction of range of motion (specifically, subtle loss of the knee extension) may be the most important clinical finding for the diagnosis of this condition.1 Differential diagnosis is often a meniscal tear because the conditions share several common symptoms (Table). The purpose of this case review is to highlight the challenges associated with diagnosis, particularly when diagnostic imaging fails to depict the severity of the condition.
Table: Comparing Clinical Signs and Symptoms of Osteochondritis Dissecans with Those of Meniscal Tears9,10,12,15–18
Half way through the first month of soccer season, a 22-year-old woman experienced an acute onset of right knee pain while running and planting her foot to cut to the left. She reported that she felt a crack in her right knee and immediate pain. Despite the pain, she was able to remain weight bearing but was unable to continue participating in the game. She attempted to run and reported increasingly severe pain on the lateral side of her knee and a sense of instability. She presented with an antalgic gait, point tenderness over the lateral joint line, lateral tibial plateau, and superior and medial to the patella.
On initial examination at the sideline of the game field, no ligamentous laxity was identified, and McMurray’s, Apley’s compression, and Wilson’s tests were negative. Strength was graded 5/5 for knee flexion and extension compared bilaterally, but the athlete had pain in end-range extension. Because all tests proved inconclusive and strength was normal, the athlete was instructed to complete a series of functional activities, including double leg jumps, single leg jumps, ball handling, and straight line running, but complained of sharp pain and sensations of instability. She was then held from participation for the remainder of the game. Her history included an anterior cruciate ligament reconstruction and a repaired OCD of the lateral femoral condyle on the contralateral side 1 year and 6 months prior, respectively, and a medial meniscectomy for a small defect on the ipslateral side of pain 18 months earlier.
The day following the injury, the athlete presented with a mild effusion and complained of pain with weight bearing except when the knee was maintained in full extension. Movement from 30° to 0° of active extension was the most painful; using stairs, specifically going down, was also painful. Her pain was localized to the lateral joint line and lateral tibial plateau. Potential diagnoses included a lateral meniscal tear, patellar subluxation, tibial plateau contusion/fracture, loose body, or an OCD. Magnetic resonance imaging (MRI) was performed to further investigate the injury.
The MRI revealed a 4×2-mm grade IV OCD over the posterior lateral femoral condyle (Figure 1). There was also a small amount of uptake at the medial patellar retinaculum indicating a mild patella subluxation. The MRI of her involved right knee 18 months prior to the most recent incident due to another injury showed no signs of OCD that time, and she recovered fully. Thus, the lesion was judged to be acute. Due to the apparent small size of the lesion, surgical intervention was not recommended. A plan of rehabilitation was developed to address symptoms and maintain function. The athlete was cleared to continue soccer participation for the remaining 8 weeks of the season. Rehabilitation consisted of quadriceps and hamstring strengthening, increasing neuromuscular control, pain management, and limited participation based on signs and symptoms.
Figure 1. Magnetic resonance imaging indicating osteochondritis dissecans. (A) Full thickness osteochondritis dissecans (arrow) is shown. (B) Defect and associated bone edema (arrow) are shown.
The athlete would come to the athletic training room before every practice and game to evaluate the size of her effusion daily. If her effusion was moderate in size, she was excluded from participation in soccer. On days that she could not practice, cardiovascular conditioning was maintained by using a stationary bike and interval training or by pool workouts. Pool workouts included treading water, using the aqua jogger, or freestyle swimming. The Game Ready System (CoolSystems, Inc, Alameda, Calif) (a device that combines ice water with compression in addition to interferential stimulation) was used before and after practices daily. Occasionally, pulsed ultrasound, contrast baths, cold tubs, compression stockings, high-volt stimulation, foam horseshoe with an elastic bandage, and kinesiotape were used to help decrease effusions when necessary. Rehabilitation included open chain eccentric and concentric quadriceps training, avoiding 0° to 30° of flexion, which was painful for the athlete. Open chain concentric and eccentric hamstring exercises were also used, again avoiding 0° to 30° degrees of flexion. Single-leg balance on uneven surfaces and box drops onto foam on days that she did not have pain were used to aid in neuromuscular control. These exercises were performed 2 to 4 times weekly to prevent atrophy while trying to decrease irritation of the joint itself. Nonsteroidal anti-inflammatory drugs were also used for pain as needed.
The athlete completed the remainder of the soccer season despite continued pain in the lateral joint line, recurrent effusion, episodes of catching and locking, and intermittent periods of instability. She was sedentary for an additional 3 weeks once the season ended in hopes of the symptoms decreasing or ceasing. Because of the continued disability, arthroscopic examination was performed at that time. Direct visualization revealed a 9×12-mm lesion that was addressed through chondroplasty. The chondroplasty consisted of 12 holes drilled to the subchondral bone to stimulate healing and debridement of the loose portions of articular cartilage (Figure 2). The surgeon (M.J.) also performed a partial medial and lateral meniscectomy, and a loose body the size of a dime, most likely from the lesion, was also removed from the joint.
Figure 2. Chondroplasty and drilled holes shown via photograph taken at time of arthroscopy.
One of the most remarkable clinical findings in this case was the acute mechanism noted with the injury. This athlete, due to an unrelated previous knee injury, had an MRI 18 months previously that did not reveal any femoral trauma indicating the acute mechanism. As previously discussed, most OCDs present gradually, presumably due to repetitive microtrauma due to shearing and compressive loads to the joint surfaces, and most patients do not report an onset of symptoms that correlate directly with an OCD.1 The acute mechanism, although a rare cause of an OCD, was reported in a case by Hixon and Gibbs1 in which a direct blow to the patella resulted in this diagnosis of the medial femoral condyle. Although the patient in the case presented by Hixon and Gibbs1 had a previous history of general knee pain, there were no other symptoms reported at the time of injury, indicating the acute nature of the OCD.
Preliminary diagnosis of an OCD can be made through history and physical examination. However, the Wilson’s test8 is the only physical examination procedure for OCD identified in texts devoted to special testing for musculoskeletal disorders. This test is intended to evaluate the presence of lesions within the medial femoral condyle and its diagnostic utility has not been extensively assessed. When an athlete presents with joint line tenderness, effusion, and limited range of motion, especially related to an acute onset, additional work-up is often indicated to identify the structural damage responsible for the impairments and associated functional limitations to confirm a diagnosis.
Magnetic resonance imaging, short of direct visualization, is the most accurate diagnostic method for an OCD, with a reported 97% sensitivity1 and 100% specificity.16 Through MRIs, the size, vascularity, and stability of the lesion16 can be assessed. However, the current case is a reminder that although MRI and other advanced technologies provide the best noninvasive means of visualizing connective tissues ever available, perfection in assessment has not been achieved.
In the current case, it is unlikely that the size of the lesion progressed through the course of care. An increase in the frequency and severity of symptoms may indicate progression of an OCD lesion2; however, in this case the symptoms persisted rather than worsened. The persistence of the athlete’s complaints ultimately lead to further examination through arthroscopy that fully exposed the extent of the defect.
It is important to note that lateral femoral condyle OCDs and bone bruising most often occur secondary to the impact of the femur on the tibia during an anterior cruciate ligament (ACL) rupture6,7 and are described as a “footprint” left at the time of the injury.5 Most isolated lateral femoral OCDs occur in adolescents1,3 or are secondary to a discoid lateral meniscus.3,11,17 In the current case, neither the patient’s age nor meniscal structure posed risks of lateral femoral OCD. Moreover, the ACL was not injured; of note, however, the patient had sustained an ACL injury with an associated lateral femoral condyle OCD on her contralateral side.
Most often, OCD results in a gradual onset with non-specific symptoms1,3,9 or occurs concomitant to ACL injury.6,7 When there is a noted, acute mechanism of injury with joint line pain, meniscal injury is often the initial concern. Physical examination is of limited value in evaluating the menisci18 and less common conditions, such as OCD. Magnetic resonance imaging offers the best noninvasive assessment of the menisci and articular cartilage. The current case demonstrates that advanced imaging is not perfect. When impairments resulting in functional loss and disability persist despite compliance with a well-intentioned plan of care, additional investigation must be pursued. In the current case, arthroscopy revealed the extent of damage and the cause of persisting disability. Although acute lateral femoral OCD is uncommon, the diagnosis must be considered when symptoms of lateral knee pain, effusion, and instability persist.
Implications for Clinical Practice
Currently, there is paucity of effective diagnostic tools available for the clinical diagnosis of OCD; therefore, when symptoms persist, worsen, or do not match the initial diagnosis, direct visualization may be necessary. A rehabilitation program needs to focus on stimulating the supporting muscles (in this case hamstrings) and the muscles that will be directly affected by a recurrent effusion—the quadriceps group. It is also important to monitor the quadriceps group closely for atrophy, especially if participation is continued; if atrophy develops, the athlete should be removed from sport involvement to decrease the risk of further injury. Although not a complication seen in this particular case review, muscle atrophy is something important to consider with recurrent effusions and knee pain.
- Hixon AL, Gibbs LM. Osteochondritis dissecans: A diagnosis not to miss. Am Fam Physician. 2000;61:151–156, 158.
- Cooper G, Warren R. Osteochondritis dissecans: Workup. http://emedicine.medscape.com/article/1253074-diagnosis. Accessed May 15, 2008.
- Hashimoto Y, Yoshida G, Tomihara T, et al. Bilateral osteochondritis dissecans of the lateral femoral condyle following bilateral total removal of lateral discoid meniscus: A case report. Arch Orthop Trauma Surg. 2008;128:1265–1268. doi:10.1007/s00402-007-0499-0 [CrossRef]
- Petrie PW. Aetiology of osteochondritis dissecans: Failure to establish a familial background. J Bone Joint Surg Br. 1977;59:366–367.
- Viskontas DG, Giuffre BM, Duggal N, et al. Bone bruises associated with ACL rupture: Correlation with injury mechanism. Am J Sports Med. 2008;36:927–933. doi:10.1177/0363546508314791 [CrossRef]
- Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med. 2005;33:1579–1602. doi:10.1177/0363546505279913 [CrossRef]
- Spindler KP, Schils JP, Bergfeld JA, et al. Prospective study of osseous, articular, and meniscal lesions in recent anterior cruciate ligament tears by magnetic resonance imaging and arthroscopy. Am J Sports Med. 1993;21:551–557. doi:10.1177/036354659302100412 [CrossRef]
- Kocher MS, Tucker R, Ganley TJ, Flynn JM. Management of osteochondritis dissecans of the knee: Current concepts review. Am J Sports Med. 2006;34:1181–1191. doi:10.1177/0363546506290127 [CrossRef]
- DellaMaggiora R, Vaishnav S, Vangsness C Jr, . Osteochondritis dissecans of the adult knee. Oper Tech Sports Med. 2008;16(2):65–69. doi:10.1053/j.otsm.2008.10.012 [CrossRef]
- Madhusudhan TR, Kumar TM, Bastawrous SS, Sinha A. Clinical examination, MRI and arthroscopy in meniscal and ligamentous knee injuries: A prospective study. J Orthop Surg Res. 2008;3:19. doi:10.1186/1749-799X-3-19 [CrossRef]
- Deie M, Ochi M, Sumen Y, et al. Relationship between osteochondritis dissecans of the lateral femoral condyle and lateral menisci types. J Pediatr Orthop. 2006;26:79–82. doi:10.1097/01.bpo.0000191554.34197.fd [CrossRef]
- Atik OS, Esen E, Tokgöz N, Ataoglu B, Taskesen A. Osteochondritis dissecans with subchondral bone cyst of the femoral condyle: A novel surgical technique of treatment. Joint Dis Relat Surg. 2009;20:174–177.
- Beyzadeoglu T, Gokce A, Bekler H. Osteochondritis dissecans of the medial femoral condyle associated with malformation of the menisci. Orthopedics. 2008;31:504. doi:10.3928/01477447-20080501-02 [CrossRef]
- Mohan BR, Gosal HS. Reliability of clinical diagnosis in meniscal tears. Int Orthop. 2007;31:57–60. doi:10.1007/s00264-006-0131-x [CrossRef]
- Rytter S, Jensen LK, Bonde JP. Clinical findings in floor layers with focus on meniscal status. BMC Musculoskelet Disords. 2008;9:144. doi:10.1186/1471-2474-9-144 [CrossRef]
- Kijowski R, Blankenbaker DG, Shinki K, Fine JP, Graf BK, De Smet AA. Juvenile versus adult osteochondritis dissecans of the knee: Appropriate MR imaging criteria for instability. Radiology. 2008;248:571–578. doi:10.1148/radiol.2482071234 [CrossRef]
- Stanitski CL, Bee J. Juvenile osteochondritis dissecans of the lateral femoral condyle after lateral discoid meniscal surgery. Am J Sports Med. 2004;32:797–801. doi:10.1177/0363546503261728 [CrossRef]
- Chivers MD, Howitt SD. Anatomy and physical examination of the knee menisci: A narrative review of the orthopedic literature. J Can Chiropr Assoc. 2009;53:319–333.
Comparing Clinical Signs and Symptomsa of Osteochondritis Dissecans with Those of Meniscal Tears9,10,12,15–18
|OSTEOCHONDRITIS DISSECANS||MENISCAL TEAR|
|Joint “locking”||Tibial anterior displacement|
|Inability to fully extend the knee||Internal rotation of the tibia relative to the femur|
|Crepitus||Pain with knee flexion|
|Stiffness after rest||Joint instability|
|Ambulation with external tibial rotation||Joint effusion|
|Pain||Joint line tenderness|
|Joint instability||Loss of function|
|Joint effusion||Decreased range of motion|
|Joint line tenderness||Sensations of “catching” or “giving way”|
|Loss of function|
|Decreased range of motion|
|Sensations of “catching” or “giving way”|