Non-surgical treatments for Osteochondritis dissecans
Ross Hauser, MD, Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
David Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
In this article, we will cover research on Platelet Rich Plasma Therapy and treatment of Osteochondritis dissecans in youth athletes as a means to help non-surgically accelerate healing. The main focus of this article will be on knees and elbows.
If you are reading this article you are likely the parent of a teenage athlete who is trying to stay in his/her sport(s). Your child has just been diagnosed with Osteochondritis dissecans. The treatment you are being recommended to includes weeks of inactivity and rest. You ask about physical therapy but are told that PT does not really help cartilage re-attach to the bone. You are told only “conservative treatment” that being rest or stopping all activities for a prolonged time or surgery can. When you explore more about the surgical aspects, you find out that while the surgery can help, it does not prevent the recurrence of your child’s Osteochondritis dissecans.
You may be struggling with the advice to have “patience,” and with your desire to help your athlete back to their game. What are your options? One option is to research and find answers. We hope to help you with that here.
Understanding osteochondritis dissecans
The knee patient
Often we will see a young patient in our examination room. The parents and the young patient will describe a knee problem that began when the knee became hyperextended during a game or gymnastics competition. The parents will tell us that they went to the “urgent care,” where they were told to use the RICE protocol of Rest, Ice, Compression, and Elevation.
After a few days of RICE, the parents tell us that there was no improvement at all and an appointment and consultation with a specialist lead to an MRI and the discovery of the osteochondral lesion and diagnosis of Osteochondritis dissecans. For many we see, there was good news in that surgery would not be recommended. For others, we see a more concerning recommendation to surgery will be given, especially in the presence of significant symptoms.
Knees: My daughter is 15 and she has osteochondritis dissecans in both knees. She also has knee instability from ligaments that need to be tightened. The specialist we are seeing wants to do surgery. She also has been diagnosed with Ehlers-Danlos Syndrome and the surgeon feels that this is causing her pain from the knee popping out of place. My daughter does not want the surgery, I am exploring options for her.
Knees: I have a 12 year old son. It is his left knee that has been the problem. He was diagnosed with osteochondritis dissecans and it was recommended going to complete 6 months of conservative treatment that included physical therapy, muscle strengthening, and exercise. After the 6 months his pain was gone, which was a blessing, however, he still has issues with function. He can walk okay but he has problems on steps, stairs, hills, and inclines. We have been to a few specialists and they each have a different opinion. Some say operate, some say don’t operate, some say wait and see. We are looking for answers but we only seem to get confused.
The elbow patient
Often we will see the young gymnast or the youth league baseball pitcher with significant elbow problems. For the gymnast, the elbow problems present a significant challenge to various routines including the floor exercises. We will often hear parents tell us about their “one-armed” gymnast. For the baseball pitcher, elbow problems mean shut down from playing.
Elbow: My son is a pitcher, or he was a pitcher. About a year ago when he was 14, he was diagnosed with osteochondritis dissecans in his pitching elbow. We were also told at that time about a fracture in his growth plate. He was immediately told to rest and immobilize his arm. This included no throwing for three months. The physical therapy was very successful, enough so that he could return to playing, he just can’t pitch because his elbow is locking up. The doctors think this is from floating pieces of cartilage in his elbow. We have to consider the surgery.
Osteochondritis dissecans is a condition of cartilage and subchondral (under the cartilage) bone damage. Young athletes are typically affected in the knee, elbow, ankle, and hip. Repetitive microtrauma from sports is a common cause, especially among older adolescents and teenagers.
Here is learning point information (March 2019) from the National Center for Biotechnology Information and STATPearls publishing at the U.S. National Library of Medicine.(1)
- Osteochondritis dissecans (OCD) or “osteochondral lesion,” is not a fully understood process. It is “idiopathic” which means that doctors are not sure how it starts and develops but they believe there are many factors that lead to this problem. Below we will discuss joint instability as one of these causes.
- Osteochondral lesions range in severity from being asymptomatic (no pain or symptoms) to mild pain or advanced cases having symptoms of joint instability and locking. As the condition develops, cartilage fragments can break away and become “loose bodies,” in the joint causing pain and inflammation. When the patient has a loose fragment, symptoms are generally more severe, with marked joint pain, locking, swelling, and joint instability.
The theory as to why your child has Osteochondritis dissecans
- Doctors think that spontaneous osteonecrosis (joint deterioration caused by reduced blood flow) is thought to occur during the transition from juvenile bone and cartilage development to mature bone and cartilage development in adolescence. The higher prevalence of Osteochondritis dissecans in young athletes suggests a repetitive microtrauma etiology.
Not growing pains
One of the problems that we see in our office is that the young athlete has not had medical treatment because of the thinking that the athlete’s problems, especially in the knee or elbow are all part of “growing pains.” As pointed out in the research we are citing and confirmed by other research studies, these young patients typically show up in the specialists’ office several months to a year after the onset of symptoms.
Understanding osteochondritis dissecans treatments in the knee
In a July 2019 study in the medical journal Cartilage, (2) research lead by doctors at the Rizzoli Orthopaedic Institute, in Bologna, Italy examined the evidence of certain nonsurgical treatment strategies for knee Osteochondritis dissecans. The researchers looked at 27 studies that totaled an examination of 908 knees.
The treatments discussed were:
- (1) restriction of physical activity,
- (2) physiokinesitherapy (movement therapy) and muscle-strengthening exercises,
- (3) physical instrumental therapies, (examples are magnetic stimulation, infrared pulsed laser therapy et al.)
- (4) limitation of weight-bearing, and
- (5) immobilization.
The analysis showed an overall healing rate of 61.4%, with large variability (10.4% in one study to – 95.8% in another).
- A conservative treatment based on restriction of sport and strenuous activities seems a favorable approach, possibly combined with physiokinesitherapy.
- Negative prognostic factors were also identified:
- larger lesion size,
- more severe lesion stages,
- older age and skeletal maturity,
- discoid meniscus, and
- clinical presentation with swelling or locking.
The researchers here concluded:
“The literature on conservative treatments for knee Osteochondritis dissecans is scarce. Among different non-surgical treatment options, strenuous activity restriction seems a favorable approach, whereas there is no evidence that physical instrumental therapy, immobilization, or weight-bearing limitation could be beneficial. However, further studies are needed to improve treatment potential and indications for the conservative management of knee Osteochondritis dissecans.”
Understanding osteochondritis dissecans treatments in the elbow
In a May 2019 study in the medical journal Cartilage (3) researchers in Germany offered these observations of the problems of treating osteochondritis dissecans in the elbow:
- What causes osteochondritis dissecans in the elbow or open growth plates “remains as unclear as for the knee.”
- Mechanical factors (throwing activities) seem to play an important role.
- Clinical symptoms are unspecific. Imaging techniques are then important for the diagnosis. In low-grade and stable lesions, treatment involves rest and different degrees of immobilization until healing.
- When surgery is necessary, the procedure depends on the OCD stage and on the state of the cartilage.
Pegs, Plugs, and Drills – Is there a surgical role for Osteochondritis dissecans?
In November 2017 in the publication Orthopaedics and traumatology, surgery and research, (4) doctors in France gave a summary explanation of the standard treatment offered to patients with osteochondritis dissecans.
- When the radiographic diagnosis of osteochondritis dissecans is made early in a patient, healing can often be obtained simply by restricting sports activities.
- The degree of lesion instability (bone or cartilage tears and cracks) can later be assessed by magnetic resonance imaging to see if healing with restricted sports occurred.
- When the lesion remains unstable (bone and/or articular cartilage tear did not repair and is loose or may tear away) and the pain persists despite a period of rest, surgery is indicated.
- Arthroscopic exploration is always the first step.
- Drilling of the lesion produces excellent outcomes if the lesion is stable. (In this procedure, is the tear flap/bone is fixed, and not a threat to breaking away and floating in the joint, drilling into the bone will bring blood to the cartilage tear and instigate healing. Please see our article Knee articular cartilage surgery and non-surgical repair for a more detailed discussion of various surgical procedures and drilling).
- Unstable lesions require fixation and, in some cases, bone grafting. (The osteo-cartilaginous block spoken about above has broken away leaving a hole in cartilage or bone or both).
The cartilage plug and the bone peg
In the journal, International Orthopaedics, (5) surgeons at the University Hospital of Montpellier suggest cartilage plugs for osteochondritis dissecans of the patella on a short-term basis. The plugs are inserted during an autologous osteochondral mosaicplasty. Cartilage is removed from a non-weight bearing part of the knee and used to replace cartilage defects in the patella. The technique has been found reliable in the short term to restore the patellar joint surface and obtain satisfactory functional results.
Doctors in Japan (6) found that bone peg grafting, the removal of bone from a non-weight bearing bone and drilling them into an osteochondritis bone defect could get adolescent baseball players back on the field in 12 months.
Osteochondritis dissecans surgical alternatives – two case studies on Platelet Rich Plasma
Research on Platelet Rich Plasma Therapy, an injection treatment that re-introduces your own concentrated blood platelets into areas of chronic joint and spine deterioration, more commonly referred to as PRP is gaining a lot of attention as a non-surgical option.
In the Journal of Prolotherapy (7) Budak Akman, MD and his colleagues at Yeditepe University Faculty of Medicine, Orthopaedics and Traumatology Department Istanbul – Turkey reported on this case.
A 16-year-old male patient presented to our hospital with a six-month history of pain in his right knee, increasing in severity over time, after having encountered a traumatic fall in a football (soccer) match 6 months prior. He reported increasing pain especially with walking long distances and physical activities, and although rare, accompanied by a sense of stumbling, friction and limping.
Showing no positive development in symptoms and physical status for six months, our 16-year-old male patient received two intraarticular platelet rich plasma injections three months apart, focusing on the lesion of osteochondritis dissecans localized in the right knee.
At the end of the 18th month, the patient did not show any limitation in his physical activities and radiographic examination confirmed the successful treatment.
Having obtained positive results, we believe that PRP injections are a safe, simple, and minimally invasive treatment option for juvenile OCD which doesn’t respond to conservative therapy before a surgical approach.
Case study in the soccer player
In the Journal of Prolotherapy, doctors presented the case (8) of a 20-year-old soccer (footballer) patient with pain in his right knee during walking and playing soccer. The problem became progressively worse over time, with the appearance of an effusion of the knee.
Clinical examination found pain in the antero-internal (front-inner side) aspect of the knee, muscle strength was normal, and there was no limitation of joint movement. Initial CT scan and MRI demonstrated osteochondral lesion of the internal femoral condyle classified as grade III.
FIRST PRP SESSION January 21, 2017
One week prior to the first PRP session, the patient received an intra-articular injection of Prolotherapy and ozone.
PRP was injected into the knee under ultrasound guidance, anteriorly into the articular space and at the contact of the lesion, visible in ultrasound.
Following the procedure, the patient was advised to walk with crutches for 3 months.
MRI and CT scan at the end of the third month showed decreased lesion size compared with the initial size, appearance of revascularization and formation of bone bridges between the fragment and the femoral condyle.
SECOND PRP SESSION June 15, 2017
The same PRP procedure was repeated, with the same intra-articular Prolotherapy injection and ozone performed one week prior.
Six weeks after the PRP procedure, the patient was allowed to walk with a cane or single crutch. Then after two months, without any aids.
After another three months of follow-up, MRI and CT scan showed complete revascularization of the fragment and attachment of 95%.
PATIENT FOLLOW-UP December 12, 2017
The patient has completely returned to soccer for 1 month (matches and full training) without pain and without effusion (ultrasound).
If you have a question about Osteochondritis dissecans, you can get help from our Caring Medical staff.
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