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Manual Therapy 11 (2006) 157–161

Case report

Osteochondritis dessicans: A complex case of anterior knee pain

John Davina,, James Selfeb

aManchester United Football Club, Birch Road, Carrington, Manchester, M31 4BH, UK bReader in Physiotherapy, Allied Health Professions Unit, University of Central Lancashire, Preston, PR1 2HE, UK 

Received 25 March 2004; received in revised form 4 February 2005; accepted 19 May 2005

1. Introduction

This case highlights the difficulty in correctly identify-

ing osteochondritis dessicans and alerts clinicians to the

fact that although previously unreported as such, the

condition may be prone to recurrence. Presenting

symptoms and early positive responses to treatment

may be misleading and indicative of dysfunction in

structures that are not responsible for the complaint.

2. The patient

The patient was a 17-year-old male, right leg domi-

nant, full-time professional football player. He appeared

to be in good health and walked confidently into the

treatment room. Movements of sitting to standing were

completed effortlessly with no obvious visual cues as to

the nature of the complaint. His past medical history

consisted of a previous arthroscopy to the left knee when

the patient was 14. This showed osteochondritis dessi-

cans, with a large flap of articular cartilage on the medial

femoral condyle. The medial femoral condyle was

successfully repaired. In addition, the patient had an

asymptomatic spondylolisthesis of L5/S1.

3. History of condition

The patient recalled a 6-month history of left knee

pain. Initially, it had not prevented him from training

but he felt it had altered his running style. He reported

that his left leg felt considerably weaker than his rightone and that this was more than the expected difference

due to leg dominance. He had not sought help at the

time of the initial pain as shortly thereafter he suffered

from glandular fever and this had enforced a prolonged

break from football.

When the patient returned to the club for pre-season

training, initially his knee felt normal. Four weeks into the

season he recalled experiencing slight knee pain. This

gradually worsened over a 2-week period until the pain

became so intense that he could not complete the warmup.

4. Subjective assessment

The patient complained of a painful left knee as well

as other symptoms (see Fig. 1). A Visual Analogue Scale

(VAS) value of 7 was given by the patient for his knee

pain. His primary complaint (P1) was described as a

diffuse dull ache around the anterior aspect of the knee,

sometimes spreading to the mid-thigh after 4–5 min of 

intense exercise including acceleration, deceleration and

change of direction exercises. P2 was a general tightness

around the knee, which came on after 20 min of 

sustained flexion. P3 was an occasional shooting pain

along the lateral aspect of the calf from the knee to the

Achilles tendon. He noted a link between P1 and P3 but

stated that P1 could be felt at rest but not P3.

5. Objective examination

The pain distribution suggested several possible

structures as the source of symptoms. A previous

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Corresponding author.

E-mail address:   john.davin@manutd.co.uk (J. Davin).

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history of an L5/S1 spondylolisthesis is a red flag

(Clinical Standards Advisory Group (CSAG), 1994).

Although the previous history suggested that the

spondylolisthesis was stable (concurrent X-rays taken

at yearly intervals for 4 years) an objective assessment of 

the lumbar spine was undertaken. This was not only to

rule out a possible source of symptoms but also to allay

the patient’s fear in terms of diagnosis. The patient’s

brother was also a professional footballer whose career

had halted early due to a congenital active spondylo-

listhesis. The patient had expressed concern at this and

any undue anxiety, as   Main and Watson (1999)   argue,

may influence pain mechanisms.

The only significant finding was related to posture.

Postural assessment revealed a thoracic kyphosis,

lumbar lordosis and anteriorly tilted pelvis. However,

footballers often present with this altered posture due to

repeated activity of the hip flexor and knee extensor

muscles combined with relative inactivity of the

antagonistic muscle groups.

Maitland (1991) notes that knee pain can be provoked

from a painless hip. Although, pain referral patterns of 

the hip as described by  Sims (1999) bore some relation

to those experienced by the patient no significant hip

abnormalities were found on objective examination.

In this case long-standing symptoms around the knee

combined with previous trauma, surgery and the

subject’s occupation (four seasons of professional foot-

ball since surgery) meant that the knee became the

primary focus of the clinical assessment.

Objective assessment of the tibiofemoral joint

consisted of palpation, active and passive movements

for flexion, extension, medial and lateral rotation

and flexion extension quadrants with and without

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Fig. 1. Patient notes linkage between P1 and P3.

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compression. All supporting ligaments were passively

stressed and gave a strong end feel. There were no other

comparable signs apart from a low-grade effusion.

Spencer et al. (1984) reported that 20 ml of saline could

inhibit the vastus medialis (VM) and 50 ml of saline

could inhibit both rectus femoris and vastus lateralis.

The presence of an extensor lag was noted which couldimplicate either the tibiofemoral joint or the patellofe-

moral joint (Maitland, 1991).

The absence of any comparable signs in the lumbar

spine, hip and tibiofemoral joint suggested that patello-

femoral joint dysfunction might be the source of the

symptoms. Objective assessment revealed a patella that

was laterally shifted, laterally tilted and externally

rotated, and tightness in the lateral retinaculum was

also noted. Altered patella positioning may adversely

affect patellofemoral biomechanics. However, it is

acknowledged that the reliability of measurements of 

patella alignment abnormalities has been reported to be

poor (Fitzgerald and McClure, 1995;   Tomsich et al.,

1996;   Watson et al., 1999). Accessory movements of 

medial glide and medial rotation to the patella gave

comparable signs.

Neural screening showed a deficit in the L3 myotome.

The lateral leg pain (P3) was further assessed in the

slump position. Left leg dorsiflexion/inversion brought

on P3 at 451 of knee flexion.

Multidirectional functional running tests provoked P1

to a level of 8 out of 10 when running backwards and

when cutting sideways from left to right. However,

similar to the extensor lag noted previously, this finding

does not discriminate between tibiofemoral or patellofe-moral dysfunction. Corrective taping was applied to the

patella and multidirectional running testing was repeated,

and this time reported pain levels were 1 out of 10.

6. Treatment

Subjective questioning and objective assessment pre-

sented a strong case for patellofemoral joint dysfunction

and the following treatment regime was instigated. It

consisted of 6 treatment sessions which included 10 min

of manual therapy and 20 min of active control work.

The patient was also instructed in a home exercise

programme. This consisted of rectus femoris and

gastrocnemius stretching (15 s 4), 10 min of plie work

using a biofeedback machine, and sliders 30 s 4 per

night.

Accessory movements to the patella gave comparable

signs and so were used as the first treatment choice.

Grade III medial glides (5 30 s) with a rest between

sets were used. After treatment 2 this was progressed to

Grade IV (5 30 s) with a rest between sets. These were

performed to the patella to mobilize the joint through a

more elastic phase and to increase joint nutrition. The

movement helps to ‘‘stir the inflammatory soup’’

(Butler, 2000, p. 53) increasing the fluid pH and

decreasing acidity. This elevates the threshold at which

nociceptors fire; a greater stimulus is therefore required

to elicit a response (Butler, 2000). Severity, Irritability

and Nature (SIN) factors (Maitland, 1991) allowed

quick progression to grade IV to stretch tightenedlateral structures.

Patellar taping (see Figs. 2–4) in this case was used to

maintain a stretch on the lateral tissues achieved in

treatment. It was applied at the end of treatment two

after it was established that medial glides (grade IV)

were beneficial in reducing pain. Although effective in

this case at significantly reducing pain, the decision to

use patellar taping is controversial as it is unclear how

the tape actually works (Harrison and Magee, 2001).

Mini squats in the plie position were instructed to

exercise the VM and complement the medial glide

mobilisation, the aim being for the patient to gain active

motor control around the patellofemoral joint. The

function of the VM is to re-align the patella medially

during extension of the knee. Any insufficiency of this

muscle will increase the lateral drift of the patella, which

may lead to patellofemoral pain (McConnell, 1986). A

portable biofeedback machine was used in treatment

sessions to ensure that the exercises were targeting the

VM. The machine was then used for the home exercises,

ensuring correct technique.

A muscle-stretching regime was instructed as part of 

the home exercise programme to enhance the general

condition of the knee joint. The influence of surrounding

musculature is open to debate.  Rouse (1996)   questionsthe relevance of the iliotibial band (ITB) and its

relationship with patellar problems.   Mercer et al.

(1999) state that the ITB is firmly attached to the linear

aspera of the femur via the lateral inter-muscular

septum. Therefore, clinical procedures for assessing/

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Fig. 2. Hypafix taping in a lateral–medial direction.

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stretching the ITB should be re-examined. In this case

no stretch was instructed for the ITB in the home

exercises. However, exercises for rectus femoris and

gastrocnemius were instructed due to their influence on

the knee joint (McConnell, 1986).

Home exercises were prescribed for the nervous

system to maintain improvements achieved in treatment

sessions. Sliders (a means of moving the nervous system

without causing tension) were used to continue nour-

ishment of the nervous system and induce mobilization

in a non-sensitive way. Sliders were used in the slump

position. As the ankle is dorsiflexed the cervical spine is

simultaneously extended. This is then reversed so that as

the ankle is plantar flexed the cervical spine is

simultaneously flexed. This aids vascular dynamics and

axonal transport along the nerve,   Butler (2000).

The treatment regime allowed the patient to return to

football training. He successfully completed two con-

secutive training sessions pain free before being dis-

charged. Unfortunately, it so happened that the

patellofemoral problem the patient had been treated

for was not the primary cause of his complaint. Shortly

after his apparent recovery the symptoms returned and a

decision was made to scan the joint. This showed a

circular articular defect, 2.5 cm in diameter on the

medial femoral condyle.

7. Discussion

Osteochondritis dessicans is a common disorder,

affecting adolescents,  Tatum (2000). According to Brier

(1999), the medial femoral condyle, particularly the

lateral portion, is the most common site for osteochon-

dritis dessicans. It occurs more regularly in boys and

patients who develop the condition tend to be very

athletically active. The disease is characterized by a

fragment of articular cartilage and subchondral bone

that becomes separated from the underlying bone.

Treatment of the condition is aimed at preservation of 

the articular cartilage.

The patient’s age, sex and occupation clearly suggest

that he could be a candidate for developing osteochon-

dritis dessicans, yet, his patellofemoral joint became the

primary focus for treatment. From a clinical-reasoning

perspective combining the information gained from the

patient’s past medical history, the objective assessment

and the evidence available from the literature were very

important; the key points were as follows:

 successful reparative surgery at the age of 14;

 significant pain relief following patellar taping duringthe assessment; and

 a literature search failed to find any previous reports

of osteochondritis dessicans recurrence.

Following the decision to treat the patellofemoral

 joint, the treatment administered had a very positive

effect on the symptoms and the patient successfully

completed two consecutive training sessions pain free;

this reinforced the consideration that the patellofemoral

 joint was the source of the symptoms.

It is interesting to speculate as to whether there was

any additional clinical testing that could have been

performed to indicate that osteochondritis dessicans was

a problem. Objective assessment of the tibiofemoral

 joint gave no comparable signs. Currently, using clinical

testing it is not possible to differentiate between femoral

condyle and meniscal dysfunction. Testing at the knee

predominantly tests the meniscal structures. Even with

compression or active loading it is difficult to attribute

signs specifically to the femoral condyle.

It is also interesting to consider why there was such an

apparent improvement in symptoms to the level where

the patient was able to complete football training, at a

professional level, pain free when the problem was the

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Fig. 3. Hypafix re-enforced with strappal in identical lateral/medial

direction.

Fig. 4. Strappal applied in a lateral supero-medial direction to rotate

patella.

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femoral condyle and yet the treatment was directed at

the patellofemoral joint. It may be that altered

mechanics at the tibiofemoral joint led to poor

patellofemoral integrity, which in turn led to repeated

micro trauma, which subsequently induced pain. One of 

the difficulties in trying to interpret this is that the

treatment package consisted of a number of componentsany of which in isolation or combination could have had

an effect.

A recent report by   Hinman et al. (2003)   may shed

some light on one of the components of the treatment

package taping. These authors report the results of a

blinded randomised-controlled trial of patellar taping in

the management of osteoarthritic knees. In this report

patellar taping was significantly more effective than

placebo and no tape in a group of patients that included

some patients who only had tibiofemoral joint disease.

Although the report suggests that patellar taping can

improve symptoms in patients who have only tibiofe-

moral problems, no explanation is provided as to how

or why this occurs. It would seem that this patient’s

condition provides another example of a femoral

condition that initially responded to patellar taping.

Further research is required to understand the mechan-

isms behind this pain-relieving effect.

8. Conclusion

In sport the role of the first contact practitioner is

already well established. In other, areas of musculoske-letal physiotherapy therapists are finding that they are

becoming first contact/advanced practitioners with

increasing levels of clinical autonomy, e.g. clinical

specialists, extended scope practitioners and consultant

therapists. It is vital that advanced practitioners wher-

ever they are based, have the skills and knowledge to

identify serious and/or unusual pathology when it

presents. This case has highlighted the need for

clinicians to remain vigilant even when patients appear

to be responding well to treatment.

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