The authors are from the Department of Exercise and Sport Sciences, School of Health Sciences and Human Performance, Ithaca College, Ithaca, NY.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank Paul Geisler, EdD, ATC, for his insight and critical review during the preparation of this manuscript.
Address correspondence to Courtney Gray, MS, ATC, Department of Exercise and Sport Sciences, School of Health Sciences and Human Performance, 14 Hill Center, Ithaca College, Ithaca, NY 14850; e-mail: email@example.com.
Articular cartilage injuries of the knee are being recognized with increased frequency in lower extremity sports that involve rotational forces and frequent pivoting (Figure 1).1,2 The incidence of osteochondral defects in the knee has been diagnosed more frequently, particularly in higher levels of soccer participation.3 Usually, athletes experience a mechanism of injury (MOI) that involves a blunt or compressive force, or excessive torsion leading to pain and disability.1,4–7 On physical examination and magnetic resonance imaging (MRI), there is usually accompanying damage noted with other structures in the knee,6–10 specifically the joint capsule, menisci, and knee ligaments.4 In approximately 80% of anterior cruciate ligament (ACL) injuries, there are associated osteochondral lesions found in the tibial plateau or femoral condyle.9 Because of the increased occurrence of osteochondral defects in soccer, a higher level of suspicion may be warranted in the case of a soccer player presenting with knee pain, particularly with a traumatic MOI.3
Figure 1. Female soccer player displaying rotational force.
A 19-year-old female collegiate soccer player without history of a prior knee injury complained of a gradual onset of medial knee pain while participating in soccer practice during the fall season of her sophomore year. No specific MOI could be recalled, but she reported increased knee pain with weight bearing activities, as well as an occasional locking sensation that had been progressively worsening over several weeks. Physical examination revealed point tenderness on the medial joint line and medial aspect of the patella, mild effusion on the medial side, observable quadriceps atrophy, and a loss of 5° of active extension. Ligament stability testing was unremarkable, but increased pain with McMurray’s testing and deep squats was noted.
The athlete was referred to the team physician, who was suspicious of a meniscal pathology and ordered radiographs and an MRI. The radiographs were unremarkable for fracture. The MRI failed to indicate meniscal pathology or injury to the cruciate ligaments, but it showed focal edema in the medial femoral condyle with adjacent edema within the articular cartilage. The evaluating radiologist made a subsequent diagnosis of a type II osteochondral defect of the medial femoral condyle. This grade was determined because the lesion extended to less than 50% of the cartilage depth (Figures 2 and 3).10 The athlete finished the entire fall soccer season with conservative management consisting of modalities for pain control and edema reduction but, due to continued knee pain and swelling, was limited from participating in most agility and sprinting drills during practice.
Figure 2. Frontal view of osteochondral defect on magnetic resonance imaging.
Figure 3. Sagittal view of osteochondral defect on magnetic resonance imaging.
Upon completion of the soccer season, she was referred to a surgeon specializing in osteochondral defect repair, who, after reviewing her case, thought that microfracture surgery was her best option based on the location and size of her defect, as well as her desire to participate in competitive soccer the following season. The patient underwent microfracture surgery consisting of debridement of the area and perforation of the subchondral bone. This technique assists in formation of a fibrin clot, resulting in a fibrocartilage formation over the defect that eventually creates a tissue repair.10 Postoperatively, the athlete was non-weight bearing for 8 weeks to protect the repair. Initial treatment consisted of continuous passive motion, ice, electrical stimulation, and biofeedback in conjunction with open kinetic chain quadriceps strengthening exercises. Non-weight bearing cardiovascular fitness and low-intensity open chain exercises of the trunk, hip, and calf muscles were also performed. At 8 weeks, she began gait training and closed chain exercises to improve the strength of the hip musculature quadriceps, hamstring, and gastrocnemius, as well as neuromuscular control of the knee. She began running at 4 months postoperatively and was slowly progressed to plyometric, agility, and functional exercises.
The athlete returned to participation during the next 3 months in a summer league and participated fully in her junior year. Throughout the duration of the soccer season, some residual knee pain was still present, but participation was not limited. A follow-up MRI was done 1 year postoperatively, which showed evidence of the lesion healing over the medial femoral condyle (Figures 4 and 5). She successfully competed her senior year without any limitations, and she noted a progressive decrease in the amount of medial knee pain experienced during the previous season.
Figure 4. Frontal view of knee on magnetic resonance imaging done 1 year postoperatively.
Figure 5. Sagittal view of knee on magnetic resonance imaging done 1 year postoperatively.
Osteochondral defects are generally the result of a traumatic or compressive shear force that leads to the sudden onset of pain and disability and are most often associated with ACL pathology.9 Although the athlete played soccer, which involves frequent jumping, pivoting, and cutting, she could not recall a specific MOI or force that led to her pain or dysfunction. The literature clearly describes the typical MOI for this type of condition to be traumatic and acute, commonly presenting with a hemarthrosis.4 Rather, the athlete described it as a gradual worsening during a 2-week period while continuing to fully participate in collegiate soccer that was having a negative effect on her performance. Szczodry et al11 found that chondrocyte death occurred to cartilage even when impacts applied were not sufficient enough to fracture the articular surface. This may support the fact that these injuries can be insidious and occur over time with repetitive low level forces. Thinner cartilage was more likely to fracture with lower forces, which may put these individuals at a higher risk for articular cartilage injuries. Active women have been shown to have thinner cartilage than their male counterparts, which may put them at the highest risk for injury, even if they are not subjected to a one-time traumatic or compressive force.11 This may explain the gradual onset of pain and dysfunction in this athlete’s case.
Usually, osteochondral defects are associated with other structural damage and are often seen with resulting ACL tears.9 Marcacci et al12 stated that isolated chondral lesions are rare and more often occur as a result of an un-identified degenerative cartilage disease such as arthritis, as opposed to a traumatic MOI. Adding to this case’s uniqueness, the MRI showed no tissue damage in her knee or degenerative disease other than the resulting defect, which was the sole source of her pain and disability. Most athletes will present with similar symptoms, but it may be hard to determine which tissues may be the exact cause of pain.
Evaluation for osteochondral defects presents a challenge because the defects may be masked by other associated structural damage. The Wilson’s sign (ie, internal rotation of the tibia with active extension reproduces pain, external rotation causes relief) has been used as a special test in the evaluation of osteochondritis dissecans and detecting osteochondral lesions on the medial condyle.13 Conrad and Stanitski13 found that it had low diagnostic value in recognizing individuals with this injury. Although this test was not performed on this athlete, it most likely would not have been helpful in detecting this injury, which reinforces the difficulty diagnosing on physical examination. Recognition and treatment of this condition is particularly important in the young athlete because of the possible long-term effects and development of osteoarthritis in the knee.13
Return rates to preinjury levels after an articular cartilage repair in the knee have been shown to be similar to the rates for ACL reconstruction and meniscal repair.1 Certain factors may influence the overall success of the surgery and rehabilitation. Mithoefer et al14 found a higher success rate for athletes returning to high-impact activity following microfracture technique if they were younger than 40 years and had smaller lesions, a preoperative interval shorter than 12 months, and no previous knee surgeries. Reinold et al15 noted that younger patients with isolated articular defects and otherwise healthy knee cartilage usually progress through the rehabilitation program at a faster rate, with fewer detrimental effects than older patients. The benefit of younger age is usually less wear on their articular cartilage, and this may allow for the rehabilitation to be accelerated.14,15 In this case, the athlete fit all of the criteria for a successful return, and although she experienced some knee pain her first competitive season following surgery and rehabilitation, she reported a decrease in symptoms for the following season.
Conclusion and Implications for Clinical Practice
This case is important because it reinforces the fact that not all cases will present in a typical fashion and may not exhibit the typical key features, which poses a challenge for clinicians. This athlete’s initial evaluation proved to be challenging because an atypical and unique case pattern initially appeared to be a meniscal tear due to the locking and medial joint line pain, mild effusion, and increased pain with a McMurray’s test and deep squat. The onset of pain and disability was gradual and occurred without a known MOI, making the suspicion of an osteochondral defect less obvious. Further, there was no other associated tissue damage in the affected knee or evidence of osteoarthritis, a finding supported by the MRI. There should be a higher suspicion of osteochondral defects when evaluating female soccer players with medial knee pain. This may be due to the demands of their sport and the likelihood of thinner knee articular cartilage compared with their male counterparts.11 The evaluation should be comprehensive and must recognize key features that do not always follow a particular pattern.
- Mithoefer K, Hambly K, Della Villa S, Silvers H, Mandelbaum B. Return to sports participation after articular cartilage repair in the knee: Scientific evidence. Am J Sports Med. 2009;37(suppl 1):167S–168S. doi:10.1177/0363546509351650 [CrossRef]
- Mithöefer K, Peterson L, Mendelbaum BR, Minas T. Articular cartilage repair in soccer players with autologous chondrocyte transplantation: Functional outcomes and return to competition. Am J Sports Med. 2005;33:1639–1646. doi:10.1177/0363546505275647 [CrossRef]
- Levy AS, Lohnes J, Sculley S, LeCroy M, Garrett W. Chondral delamination of the knee in soccer players. Am J Sports Med. 1996;24:634–639. doi:10.1177/036354659602400512 [CrossRef]
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- Baum JS, Deivert RG. Atraumatic osteochondral fracture and osteoarthritis in a collegiate volleyball player: A case report. J Athl Train. 2000;35:80–84.
- Buckwalter JA. Articular cartilage: Injuries and potential for healing. J Orthop Sports Phys Ther. 1998;28:192–201.
- Riyami M, Rolf C. Evaluation of microfracture of traumatic chondral injuries to the knee in professional football and rugby players. J Orthop Surg Res. 2009;4:13. doi:10.1186/1749-799X-4-13 [CrossRef]
- Meyer E, Baumer T, Slade J, Smith W, Haut R. Tibiofemoral contact pressures and osteochondral microtrauma during anterior cruciate ligament rupture due to excessive compressive loading and internal torque of the human knee. Am J Sports Med. 2008;36:1966–1977. doi:10.1177/0363546508318046 [CrossRef]
- Lewis P, McCarty L, Kang R, Cole B. Basic science and treatment options for articular cartilage injuries. J Orthop Sports Phys Ther. 2006;36:717–727.
- Szczodry M, Coyle C, Kramer S, Smolinski P, Chu C. Progressive chondrocyte death after impact injury indicates a need for chondroprotective therapy. Am J Sports Med. 2009;37:2318–2322. doi:10.1177/0363546509348840 [CrossRef]
- Marcacci M, Kon E, Delcogliano M, Filardo G, Baurizio B, Zaffaghini S. Arthroscopic autologous osteochondral grafting for cartilage defects of the knee, prospective study results at a minimum 7-year follow-up. Am J Sports Med. 2007;35:2014–2021. doi:10.1177/0363546507305455 [CrossRef]
- Conrad J, Stanitski C. Osteochondritis dissecans: Wilson’s sign revisited. Am J Sports Med. 2003;31:777–778.
- Mithoefer K, Williams RJ, Warren RF, Wickiewicz TL, Marx RG. High impact athletics after knee articular cartilage repair: A prospective evaluation of the microfracture technique. Am J Sports Med. 2006;34:1413–1418. doi:10.1177/0363546506288240 [CrossRef]
- Reinold M, Wilk K, Macrina L, Dugas J, Cain E. Current concepts in the rehabilitation following articular cartilage repair procedures in the knee. J Orthop Sports Phys Ther. 2006;36:774–794.