Physical Therapy Osteocondritis Dissecans

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Physical Therapist Management of anAdult With Osteochondritis Dissecans

of the Knee

APTA is a sponsor of theDecade, an international,multidisciplinary initiativeto improve health-relatedquality of life for people withmusculoskeletal disorders.

Background and Purpose. Osteochondritis dissecans (OCD) primarilyoccurs between 10 and 20 years of age. Adult patients (20 years) tendto respond poorly to nonsurgical management. This case reportdescribes the physical therapist management of an adult with OCD at

the tibiofemoral joint. Case Description. A 24-year-old woman hadinsidious onset of right knee pain. Magnetic resonance imagingconfirmed the diagnosis of OCD. Interventions included iontophore-sis, strengthening exercises, and instruction in strategies to minimize

loading across the knee. Outcome. The patient received 5 interventionsessions. At discharge and 9-month follow-up, she reported 95%function (Single Assessment Numeric Evaluation) and no pain while

performing full work duties. Discussion. This case illustrates theprocess, including the use of evidence, of making clinical decisionsabout the physical therapist management of an adult with OCD.[Johnson MP. Physical therapist management of an adult with osteo-

chondritis dissecans of the knee. Phys Ther. 2005;85:665675.]

Key Words: Cartilage diseases, Clinical decision making, Connective tissue, Iontophoresis, Knee injuries.

Michael P Johnson

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CaseReport


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Osteochondritis dissecans (OCD) is the sepa-ration of articular cartilage and its adjacentunderlying subchondral bone from the artic-ular surface of a joint.1 Koenig2 first

described this condition in 1888, initially hypothesizingthat it was an inflammatory disease. Later, a lack ofevidence for the presence of an inflammatory process in

the region of the articular lesion led Pappas3

to namethe condition osteochondrosis dissecans. Althoughsome authors4 support this nomenclature, the termosteochondritis dissecans is generally used throughoutthe literature. The etiology for this type of osteochondralinjury is not completely understood and varies accordingto different authors. Hypotheses include: (1) traumafrom chronic, repetitive normal loading, (2) ischemia,(3) genetic factors, and (4) endocrine-related causes.2,48

Osteochondritis dissecans can occur at many joint artic-ulations; however, it is most common in the femoralcondyles, talar dome, and capitellum.3,7 The femoral

condyles are the site for 75% of the lesions.9 Theincidence of OCD of the knee is 3 to 6 out of every10,000 people.10 It occurs most often between the agesof 10 and 20 years and is twice as common in males as infemales.10,11

Osteochondritis dissecans at the knee can occur alongthe inferior surface of the patella, the lateral femoralcondyle, or, most commonly, along the medial femoralcondyle. Location on the medial condyle accounts forapproximately 75% to 85% of all femoral lesions.3,8

These lesions are typically located along the lateral

aspect of the medial condyle within the intercondylargroove11; however, they can extend more mediallyalong the weight-bearing surface of the condyle (Fig. 1).Lesions on the medial femoral condyle tend to belocated more anteriorly compared with those on thelateral condyle.12,13 Hughston et al13 used a lateralradiograph of the knee to examine anterior or posteriorpositioning of OCD lesions. They characterized lesionsas: (1) located directly distal to a line drawn parallel tothe posterior cortex of the femur or (2) lying posteriorto that line. The location of the lesion determined when

during the knee range of motion (ROM) it was engagedby the tibia (Fig. 2).

Sanders and Crim stated that knowing when to pre-scribe conservative versus surgical therapy requires stag-ing of the lesion.4(p356) Many diagnostic imaging meth-ods (eg, radiography, magnetic resonance imaging[MRI], technetium 99m pyrophosphate joint scintigra-phy, bone scans), as well as arthroscopic examination,have been used in an attempt to stage or classify osteo-chondral lesions.4,9,14,15 The stages (typically 3 or 4

levels) represent a continuum of tissue degenerationleading to complete disruption and instability of thelesion (loose body). Originally, staging was determinedbased on radiographic findings.16 Currently, MRIappears to be the preferred choice for detection of thistype of chondral injury4,9,15 and for determining alesions stability.15,17 In 2001, Sanders and Crim,4 in theirreview of osteochondral injuries, described one of themost commonly used MRI staging schemas (Table). Thisschema (5 stages), along with a comparative radio-graphic schema,16 describes common imaging findingsassociated with OCD lesions (more stablestages 1 and2, less stablestages 3 and 4). Unstable osteochondral

lesions most often require surgical intervention.5,7,9,18In an attempt to specifically identify unstable lesions,De Smet et al17 described the use of 4 findings (con-sistent with stage 3 and 4 lesions) on MRI to predictlesion stability (n31 with lesion on the femoral con-dyles, mean age25.7 years). They reported 97% sensi-tivity and 100% specificity using this method, noting thatthe most common finding associated with instabilitywas the presence of a high signal intensity line under-neath the OCD lesion.

MP Johnson, PT, MS, OCS, is Director of Professional Development, Mercy Rehab Associates, 1503 Lansdowne Ave, Darby, PA 19023 (USA)

([email protected]).

The author thanks his 24-year-old patient for her willingness to support the presentation of her case. The assistance provided by Thomas Kain, III,

MD, was most valuable. The thoughtful commentaries and encouragement provided by Dr Rebecca Craik and Dr Kelley Fitzgerald on this article

were very helpful and greatly appreciated. Lastly, the author expresses sincere thanks and gratitude to his colleagues at Mercy Rehab Associates

for their support, encouragement, and unfailing dedication to their patients and the profession of physical therapy.

This work was presented, in part, at the Annual Conference of the Pennsylvania Physical Therapy Association, October 26 28, 2001, Seven Springs,

Pa, and at the Combined Sections Meeting of the American Physical Therapy Association, February 2023, 2002, Boston, Mass.

This article was received September 7, 2003, and was accepted December 13, 2004.

This case illustrates the combination of

current best evidence and the patients

individual needs and expectations

from physical therapy when making

clinical decisions about care.

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A variety of surgical methods exist for the managementof articular cartilage lesions at the knee, such as OCD.These include the use of arthroscopic lavage or debride-ment, radio frequency energy, bone drilling, osteochon-dral autografts or allografts, internal fixation of bonefragments, and autologous chondrocyte implantation(ACI).18 Rehabilitation following surgical interventionfor chondral lesions of the knee, which depends on thetype of procedure used, generally includes limited

weight bearing (4 6 weeks), active andpassive ROM exercise, isometricstrengthening exercises of the quadri-ceps femoris muscle, and weight-bearing and nonweight-bearing exer-cises through a limited arc ofmotion.18,19 The reader is referred to

Sellards et al18

and Irrgang and Pez-zullo19 for more in-depth informationregarding both surgical managementand postsurgical rehabilitation ofchondral lesions. Pappas3 developed aclassification schema for OCD that wasbased on outcomes. His classificationwas determined according to age cate-gories, based primarily on skeletal mat-uration: category Igirls up to 11 yearsof age and boys up to 13 years of age,category IIgirls between 12 and 20years of age and boys between 14 and

20 years of age, and category IIIpatients 20 years of age or older.

Patients in categories I and II wereconsidered skeletally immature, gener-ally having open epiphyseal platesresulting in continued musculoskeletalgrowth. Patients in category III wereconsidered skeletally mature, withclosed epiphyseal plates. Pappas3 andother authors8,9,12,20 contended thatthe prognosis for healing of symptom-

atic lesions in adult, skeletally maturepatients (20 years of age) without theassistance of surgical intervention ispoor. Hinshaw et al9 suggested thatsymptomatic OCD lesions on the fem-oral condyles most often require sur-gery in adult patients to promote heal-ing. In a multicenter, retrospectivestudy, Hefti et al8 found improve-ments in knee outcomes after bothconservative and surgical manage-ment with patients who still had an

open epiphysis compared with thosewho were skeletally mature.

Conservative management for juvenile and adultpatients with stable lesions may consist of: (1) nonweight bearing for 6 to 8 weeks,5,20 followed by restrictedsports and other activities for 6 weeks5,7,20,21; (2) kneeimmobilization5; (3) daily ROM exercises5; and (4) iso-metric strengthening exercises.5 A return to normalactivities is advocated only after clinical and diagnostic(MRI, radiograph) evidence indicates that the lesion hashealed.5 I found only 2 articles5,8 that listed interventions

Figure 1.Common sites of femoral lesions. Reprinted with permission from Aichroth P. Osteochondritis

dissecans of the knee: a clinical survey. J Bone Joint Surg Br. 1971;53:440447.

Figure 2.Areas used to define the location of osteochondritic lesions on the lateral radiograph using areference line drawn parallel to the posterior cortex of the femur. The parameters of motiondescribed indicate the ranges in which the femoral lesion is engaged by the tibia. Reproducedwith permission from Hughston JC, Hergenroeder PT, Courtenay BG. Osteochondritis dissecansof the femoral condyles. J Bone Joint Surg Am. 1984;66:13401348.

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used in the conservative management of adult patientswith stable lesions. Few of the interventions listed,however, included details necessary for use in patient

management.

Although the age of the patient and stability of the lesionare considered important prognostic variables, otherfactors need to be taken into account, such as the size22

and location8,11,12 of the lesion, when making the clinicaldecision about how to effectively manage an adultpatient with OCD of the knee. In addition to age, Heftiet al8 found better outcomes with conservative manage-ment on follow-up examination (mean4 years afterintervention, range120 years) in patients (n79) whohad favorable conditions at the knee during initial

examination. According to Hefti et al, favorable con-ditions include all 3 of the following findings: (1) no tomoderate joint effusion, (2) fragment diameter20 mm, and (3) no gross dissection (instability) of thelesion seen with diagnostic imaging. The sample in thisstudy consisted primarily of children (mean age13years 3 months). Some of those receiving conservativemanagement (n154) who had favorable conditionsat the knee, however, were adults, as defined by a closedepiphysis.

Conservative management of adult patients (20 years)with OCD of the knee is rarely recommended in theliterature.3,5,9,20 Evidence suggests, however, that someadult patients with OCD may benefit from physicaltherapist management. The purpose of this case reportis to describe and discuss the examination, evaluation,and decisions related to physical therapist managementof an adult with OCD at the tibiofemoral joint.

Case Description

HistoryThe patient was a 24-year-old woman with a 1-monthhistory of intermittent right knee pain. Her knee pain

increased rapidly within 1 week, which she associatedwith an increase in work-related activities. She was acardiac intensive care nurse and had been expected towork 12-hour shifts requiring prolonged lower-extremityweight-bearing activities. An evaluation by an orthopedicphysician shortly after the onset of symptoms resulted ina prescription for Celebrex* to reduce pain and inflam-

mation and a reduction in the length of her work shiftsfrom 12 to 8 hours. The patient reported that thesemeasures halted the progression of the right knee pain,but her symptoms persisted 1 month later. Radiographsrevealed no bony or soft tissue abnormalities, whereasMRI showed an absence of marrow edema and subtlechanges in the subcortical marrow beneath the innerweight-bearing surface of the medial femoral condyle(inferocentral). This finding was consistent with a stage2 osteochondral lesion. The patient was subsequentlyreferred by her orthopedic physician for physical thera-pist examination and intervention with a diagnosis ofOCD of the right knee.

The patient reported that, before the onset of symptoms,she was able to work a 12-hour shift and walk recreation-ally 3.2 to 4.8 km (23 miles) an average of 3 to 4 days aweek. At the time of the initial physical therapy visit, shesaid she could work a maximum of 8 hours and wasunable to walk regularly for exercise because of contin-ued right knee pain. She also said that she was unable togo up or down stairs, kneel on the front of her knee, sitfor more than 20 minutes, or drive a car without anincrease in pain. The Single Assessment Numeric Evalu-ation (SANE)23 was used to assess function of her knee,

which she rated as 55% of normal. The SANE is aself-report measure that requires the patient to rate thepresent level of function on a numeric scale from 0 to100 (100normal function). The score represents asimple, quantitative outcome measure that captures thepatients own perception of function. This scale hasbeen validated against a modified Lysholm knee score,24

a functional questionnaire that incorporates a numericactivity score (r.58.87).

The patient described her symptoms as general achingalong the anteromedial aspect of the right knee. The

knee was pain-free in the morning, but her symptomsslowly increased throughout the day. Rest (nonweightbearing) and the use of ice were effective for temporarilydecreasing and controlling knee pain. At the time of theinitial examination, she stated that her pain was 1 out of10 on an 11-point numeric rating scale (NRS) (0nopain and 10the most excruciating pain you have everfelt).25 She reported that her knee pain increased to 10during prolonged standing and walking, especially bythe end of her work shift. The test-retest reliability

* Pfizer Inc, 235 E 42nd St, New York, NY 10017.

Table.Staging of OCD Lesions Using Radiographic and MagneticResonance Imaging (MRI) Findingsa

Radiographs T2-Weighted MRI

Stage 1 Normal Marrow edema (diffuse or reticularhigh signal intensity)

Stage 2 Semicircular

fragment

Low-signal line surrounding the

fragmentStage 2a Subcortical

lucencyHigh-signal fluid or cyst(s) within

fragmentStage 3 Semicircular

fragmentHigh-signal line surrounds

fragmentStage 4 Vacant donor site

or loose bodyVacant donor site or loose body

a Reprinted with permission from Sanders and Crim.4



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(Pearson r) of the 11-point NRS for pain has beenestimated to be .67 to .96.26 Von Korff et al25 reviewedliterature related to the use of this NRS in patients withacute, chronic, and postoperative pain and concludedthat it has acceptable validity and sensitivity to change.

The patient reported a medical history that included a

previous episode of right knee pain (approximately 5 6years earlier) that resolved without medical intervention,migraine headaches, polycystic ovary disease, cardiovas-cular hypertension, von Willenbrand disease (a commonhereditary bleeding disorder with predominantly mildclinical symptoms), and a family history of OCD (sister).She said she took 3 prescription medications before hercourse of physical therapy: Accupril* to decrease bloodpressure, Celebrex for pain and inflammation, andLoestrin* for birth control.

The patient did not smoke or drink and planned to bemarried in 2 months. Her goals for therapy included:

(1) avoiding surgery, (2) returning to work at fullcapacity with minimal knee pain, and (3) walking downthe aisle at her wedding with no knee pain wearinghigh-heeled shoes. She was particularly concerned aboutnot losing any further work time because of a need tosave money for her upcoming wedding.

Examination

Observation. The patient had an endomorphic bodytype and reported that she was approximately 30 lb(13.5 kg) over her normal weight and had been so for

more than 1 year. No lower-extremity bony alignmentabnormalities were noted. No joint swelling or effusionwas observed in either knee.

Range of motion. Passive and active knee flexion andextension, measured with the patient in a supine posi-tion, were within normal limits bilaterally.27 Pain wasreproduced with end-range overpressure during bothextension and flexion testing of the right knee. Thepatient reported greater pain with passive knee exten-sion than flexion.

Muscle performance. Manual muscle testing was per-formed in accordance with the manual muscle testingprocedures described by Kendall et al.28 The patientsquadriceps femoris and hamstring muscles were ratedNormal for the left knee. Both muscles were ratedFair for the right knee. She reported anterior jointpain during resistance testing of the right knee, but didnot describe pain arising from the tendon or musclebellies of the quadriceps femoris and hamstring muscleson the right leg. It was plausible that her inability orunwillingness to generate normal contractile force was

the result of pain rather than of the presence of truemuscle weakness.

Muscle length testing also was performed according toprocedures described by Kendall et al.28 Testing revealedno length restrictions of the quadriceps femoris, ham-string, tensor fasciae latae/iliotibial band, gastrocne-

mius, or soleus muscles in either lower extremity. Thisfinding suggested that limitations in muscle length werenot contributing to abnormal forces or loads at the lowerextremity during activity. Although some informationabout muscle length can be inferred from a ROMassessment (ie, hip adduction and tensor fasciae latae/iliotibial band), this assessment cannot provide informa-tion about the length of the hamstring muscles, forexample. In addition, proper examination of musclelength requires standardized testing methods that arenot equivalent to those used for ROM measures.

Special tests. All special tests were performed asdescribed by Magee.29 The patient demonstrated noabnormalities with neurological testing, including sen-sory, dermatome, and myotome screening exams.

Ligamentous stability tests were performed on bothknees. Varus and valgus stress tests performed at 0degrees and 30 degrees were negative. Lachman andanterior and posterior drawer tests revealed no apparentcruciate ligament insufficiencies. Meniscal integrity wasnot tested during the examination because the patientreported increased pain when initially attempting eitherthe McMurray or Apley compression tests. The patellar

grind test, however, caused no increased pain.

Gait. The patients gait pattern suggested a painfulright lower extremity. Observed deviations from normalincluded decreased stance time and heel-strike andlimited knee ROM during the swing phase. The patientavoided full knee extension during swing, which limitedheel-strike.30

Palpation. Palpation was performed with the kneeflexed at 45 degrees to expose the area where the lesionwas located according to the MRI report. She reported

mild tenderness along the medial femoral condyle on theleft knee (rated as 2/10 pain), but more point tender-ness was noted with direct palpation to the inferocentralmedial femoral condyle on the right knee (rated as 8/10pain). She reported no specific tenderness with palpa-tion along the joint line medially, laterally, or posteriorlyon the right knee.

EvaluationThe key examination findings included decreased toler-ance to weight bearing activities, stance time, and termi-nal knee extension during gait, as well as increased pain



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with passive overpressure into knee extension and pal-pation along the anteromedial right femoral condyle.These findings led to the hypothesis that the patientsfunctional limitations were associated with the loading ofabnormal tissue (stage 2 osteochondral lesion via MRIfindings) along the weight-bearing surface of the con-dyle. Considering the diagnostic imaging and clinical

findings, I thought that the patients lesion was locatedanteriorly on the weight-bearing surface of the condyle.Her pain was reproduced most intensely during passiveknee extension (lesion engaged13) and direct palpationto the area. This was consistent with her unwillingness tofully extend the knee while walking and self-reports ofpain mostly with prolonged standing (knee in relativeextension) and walking.

I determined that the patient had impaired muscleperformance and motor function associated with local-ized inflammation and connective tissue dysfunction onthe articular surface of the right medial femoral condyle.

The diagnostic classification was Pattern 4D, ImpairedJoint Mobility, Motor Function, Muscle Performance,and Range of Motion Associated With Connective TissueDysfunction in the Guide to Physical Therapist Practice.31

Despite the evidence suggesting the lack of an inflam-matory process associated with OCD,3 I could not becertain that a localized inflammatory process, such assynovitis, was not active in her knee because of recenttissue overuse.32

A paucity of literature exists to guide clinicians inphysical therapist management for an adult with OCD

of the knee. Although some authors3,5,8,22 report thatconservative management of an adult is not prudent,others4,11 encourage the inclusion of age, characteristicsof the lesion (size, location, stability) as determined withdiagnostic imaging, and symptoms present when makinga decision about nonsurgical care.

Consultation with the orthopedic physician confirmedthat the lesion was relatively small (20 mm) andstable (stage 2) according to MRI findings. The physicaltherapist examination and MRI findings indicated thatmy patient had favorable conditions8 for conservative

management. These conditions included: (1) no swell-ing or joint effusion, (2) lesion size 20 mm, and (3) nogross dissection (instability) of the lesion. Consultationwith the patient revealed her strong desire to pursuenonsurgical management and a willingness to adhere tointervention. Her medical comorbidities were not con-sidered to be complicating factors for physical therapyintervention because of appropriate medical manage-ment. The patients age, diagnostic image findings(stage 2 stable lesion), clinical presentation (favorableconditions for nonsurgical management), and her spe-cific goals for therapy given her present life circum-

stances (the need to continue working and avoid surgerydue to her upcoming wedding) led me to believe thatphysical therapy intervention was warranted.

A review of the literature revealed no studies thatspecifically addressed the use iontophoresis for patientswith OCD of the femoral condyles. Many authors,3337

however, have reported the effects of anti-inflammatorymedication delivery via iontophoresis in patients with avariety of inflammatory musculoskeletal conditions,including infrapatellar tendinitis,32 plantar fasciitis,33

rheumatoid arthritis of the knees,34,35,37 epicondylitis,and metatarsalgia.35 In particular, Gudeman et al33 andHasson et al37 reported that the use of iontophoresiswith dexamethasone phosphate (DEX-P) reduced painand improved early tolerance of a therapeutic exerciseprogram. Therefore, I made the decision to use ionto-phoresis with DEX-P as a part of the intervention planbased on this evidence. Other interventions were chosenin an effort to minimize stress to the osteochondral

lesion.

InterventionThe patient participated in 5 physical therapy sessions ata frequency of 1 to 2 visits per week. Interventions toaddress the patients complaints and impairments beganon the initial visit. The treatment addressed right kneepain and provided the patient with strategies to decreaseloading across the right knee. Iontophoresis was per-formed using an Iomed Phoresor II unit with DEX-P(4 mg/mL solution) applied locally over the rightanteromedial femoral condyle (Fig. 3). The patient was

seated in a supported, long-sitting position, with an 8-in(20.3-cm) bolster placed under both knees. The purposefor the right knee position was to expose the site of thelesion on the anteromedial femoral condyle. Before theapplication of iontophoresis, moist heat was applied tothe anterior knee for 5 minutes to hydrate the skin in aneffort to aid drug delivery to the subcutaneous tis-sues.38 Palpation confirmed the site of tenderness and asmall Iogel electrode was placed over this site. Thisserved as the active electrode (anode). A dispersiveelectrode (cathode) was placed approximately 6 to 8 in(15.220.3 cm) distally on the medial calf. The skin was

cleaned at both sites with rubbing alcohol prior to theapplication of electrodes.

The iontophoresis consisted of a 1.5-mA current, deter-mined by patient comfort, applied for approximately 27minutes to achieve a dosage of 40.0 mAmin. The dosagewas consistent with that recommended by Costello andJeske.39 Upon completion of the iontophoresis, the skinunder the active and dispersive electrodes was examinedfor any abnormal reactions to the direct current stimu-

Iomed Inc, 2441 South 3850 West, Ste A, Salt Lake City, UT 84120.



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lation. No abnormalities in the skin condition beyondmild erythema were noted. The active electrode wasthen resecured with tape and the patient was instructedto leave it in place for 8 to 12 hours as tolerated. Thepurpose for this was to promote continued diffusion ofthe DEX-P medication via the reservoir effect mecha-nism of the skin.38

The patient then was instructed in joint protectionstrategies to decrease loading across the right tibiofemo-ral joint. First, the patient was encouraged to use cush-ioned footwear (ie, running shoes) to limit groundreaction forces at the knee. The patient had previouslyworn clogs at work, which had a firm sole and minimalfoot control through the upper shoe. Second, she wasinstructed to avoid end-range knee extension, includingduring the gait cycle, because this position most effec-tively engaged the lesion. In particular, I made a con-scious decision to avoid correction of her gait deviations

(limited knee extension, stance time and heel-strikeon the right) during this early stage of treatment. Third,I discussed the benefit of using an assistive device(ie, straight cane) to provide unloading of the righttibiofemoral joint. The patient, however, was reluctant touse an assistive device and decided instead to initiate thefirst 2 strategies. We agreed to discuss using an assistivedevice again if her pain did not improve within the firstweek of treatment.

A home exercise program was initiated to address thedecreased muscle performance of the right lower

extremity. The exercises included modi-fied heel slides and modified straight-leg-raising exercises. Modified heel slides(3090) were used to promote painrelief and tissue healing throughincreased synovial fluid diffusion. Rangeof motion limits at the knee were used to

avoid stress to the lesion site. Modifiedstraight-leg-raising exercises were per-formed with the knee held in approxi-mately 30 degrees of flexion. Single-planehip flexion (in a supine position), exten-sion (in a prone position), abduction (in aleft side-lying position), and adduction(in a right side-lying position) were per-formed within full available hip ROM for2 sets of 10 repetitions each. These exer-cises were chosen to strengthen the 2-jointmuscles that cross the hip and knee joints,to allow for improved load attenuation by

these muscles (ie, rectus femoris, ham-string group, gracilis, and tensor fasciaelatae/iliotibial band).28 The decision toperform these exercises with the kneefixed in 30 degrees of flexion was an effort

to protect the OCD lesion from further loading whileinitiating strengthening exercises on day 1 of herintervention.

The patient reported a 50% improvement in her symp-toms by the second visit, which occurred 5 days after theinitial examination. Given the rapid change in her right

knee pain at that time, I concluded that the need toconsider using an assistive device was no longer war-ranted. The second and third visits included applicationof iontophoresis (as described previously), review of thehome exercise program, and continued monitoring ofright knee symptoms and joint protection strategies.

On the fourth visit, 11 days after her initial visit, thepatient reported minimal, intermittent right knee pain(01/10) and increased tolerance of all activities. She,however, was still working an 8-hour shift (versus a12-hour shift before injury) and had not yet resumed her

regular walking program. The intervention for this visitremained iontophoresis with DEX-P to the right knee,monitoring of her home exercise program (with anincrease to 3 sets of 15 repetitions for all exercises astolerated), and consultation regarding continued impor-tance of joint protection. Re-examination of gaitrevealed a more normal gait pattern, with minimal painnoted during either the right lower-extremity stanceor heel-strike phases. We discussed a plan to progressher exercise program next visit and began dischargeplanning.

Figure 3.Iontophoresis treatment applied to the right anteromedial femoral condyle with the patientseated in a supported, long-sitting position and the knee flexed to expose the lesion site.



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The patient missed a visit and returned for her fifth andfinal visit 10 days after the fourth visit. She reportedcontinued improvement in right knee pain (pain rating0/10) and functional activity tolerance, noting an abilityto resume walking her dog for short distances (121 mile) without increased knee pain. She reportedminor fatigue in the right lower extremity at the end of

her 8-hour workday. Iontophoresis was discontinuedgiven her 0/10 pain rating maintained over a 10-dayperiod. A full re-examination was performed and adecision for discharge was made in agreement with thepatient. Her home exercise program was modified toinclude strengthening exercises for the muscles aboutthe hip, knee, and ankle that required movement of thetibiofemoral joint. These exercises included modifiedwall slides (2090) and modified active knee extension(9020) in an effort to promote improved strengthand endurance in knee extension through a greaterROM while still avoiding excessive loading to the OCDlesion. Patient education during this last visit included a

final review of joint protection strategies at the righttibiofemoral joint and discussion of the importance ofintegrating regular strengthening exercises into herdaily routine as a long-term method to protect the jointsof the lower extremity.40,41

OutcomesThe patient progressed well throughout her course ofphysical therapy. Her right knee pain, at worst, haddecreased by 50% (5/10 versus 10/10) by the secondvisit, it was rated as 0/10 to 1/10 (on average) by thefourth visit, and she experienced no pain with any

functional activities at discharge. She reported only mildtenderness along the anteromedial femoral condyle onthe right knee (pain rating 4/10) with direct palpationto the area. Upon discharge, ROM at the right tibio-femoral joint remained within normal limits, and nopain was noted with passive end-range flexion or exten-sion overpressure to the joint. Her muscle strength wasrated as Normal for both the right knee flexors andextensors, although she did describe fatigue in theright lower extremity after a full day of work (8 hours).She demonstrated no observable gait deviations duringambulation, noted the ability to walk her dog for 12 to 1

mile without difficulty, and reported a 95% rating offunction (SANE score). Although the patients workstatus continued with a limited 8-hour shift, she reportedno pain throughout the work day and was planning toresume her normal 12-hour shift within the 2 weeksfollowing discharge from physical therapy.

At the 9-month follow-up (from initial examination), thepatient reported good right knee function (95% SANEscore) with all activities and no pain (0/10). She hadbeen working 12-hour shifts consistently for more than 6months and was able to walk down the aisle at her own

wedding without difficulty wearing high-heeled shoes.Unfortunately, the patient did not complete a follow-upMRI, which had been scheduled 1 year after the initialMRI; therefore, no comparative imaging was available toassess healing of the lesion.

Discussion

This case report focused on the physical therapist man-agement of an adult (20 years) female patient withOCD of the right knee. She received physical therapyintervention that included iontophoresis with DEX-P,strengthening and ROM exercises that were modified tolimit stress to the lesion, and patient education on jointprotection strategies. Despite recommendations againstconservative management of adults with OCD3,5,9,20 andlimited guidance from the literature regarding specificinterventions5,8 for this population, the patient madeexcellent improvement in her impairments and func-tional limitations after a relatively short course oftreatment.

Some authors have argued that several factors areresponsible for the increased potential of DEX-P diffu-sion into the underlying tissues with iontophoresis:polarity of the active electrode,4245 localized cutaneousblood flow,43,46 pH level in the skin,47 and currentintensity.43 Although use of the anode as the activeelectrode was originally posited by Glass et al,48 manyauthors4245 have recently provided persuasive argu-ments for the use of the cathode. At the time I treatedthis patient, there were discrepancies in the literatureand among the clinical pharmacy staff at my facility

regarding use of the anode or the cathode as the activeelectrode with DEX-P. Based on current evidence, how-ever, my facility has been using the cathode consistentlyas the active electrode when providing iontophoresis ofDEX-P for the past 4 years.

Early work by Singh and Roberts,46 using salicylic acidwith rats, suggested that increased cutaneous blood flowaided clearance of the solute from the skin. Althoughlittle direct evidence that this effect exists in humans, itis credible to suggest that using thermal modalitiesbefore or after iontophoresis may diminish the reservoir

of medication in the skin available for diffusion todeeper tissues. Anderson et al43 also hypothesized thatincreased cutaneous blood flow, resulting from high-current iontophoresis (1.54.0 mA), may aid clearanceof DEX-P, resulting in lower penetration of the drug intosubcutaneous tissues.

Recent studies44,45 have shown an absence of DEX-P inthe synovium and local venous blood after the applica-tion of iontophoresis delivered at a 4.0-mA current.These findings may suggest: (1) a lack of effective DEX-Pdelivery into the subcutaneous tissues or (2) that the



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amount of drug delivered was at a level below detectionby the methods used in these studies.

Considering the parameters under which my patientreceived iontophoresis of DEX-P, it is reasonable tosuggest that, in light of recent evidence, delivery ofDEX-P into the target tissue was minimal and unlikely to

account for her pain relief. The application of transcu-taneous direct-current electrical stimulation during ion-tophoresis, however, may have been partially responsiblefor her early pain relief.

Many authors4952 have studied the effects of transcuta-neous electrical nerve stimulation (TENS) on pain reliefin human subjects. Although some authors demon-strated that high-frequency stimulation had the besteffect on a subjects perception of experimentallyinduced pain,5052 others described how both high- andlow-frequency applications of TENS could be effectivefor pain relief.49,53 In a recent review of nonpharmaco-

logical treatments for musculoskeletal pain, Wright andSluka53 reported evidence that TENS improves jointfunction in patients with rheumatoid arthritis. Theseauthors, along with Ulett et al,49 also reported on theeffectiveness of both high- and low-frequency TENS(ie, electroacupuncture) to inhibit pain through cen-trally mediated responses in animals and humansubjects.

Iontophoresis was delivered to the anteromedial, rightknee of my patient through direct-current (low-rate)stimulation for a period of 20 to 25 minutes per treat-

ment session. These parameters, although not identicalto other forms of TENS commonly used to achieveanalgesia, are similar to low-frequency electroacupunc-ture (2 Hz, 30 minutes).49 It appears reasonable, there-fore, to suggest that her early decreases in pain may havebeen aided, in part, by the current application from thephoresor unit during treatment application.

It is also possible that the early decrease in symptomsmay have been the result of factors other than, or inaddition to, the application of electrical stimulation(eg, a change in footwear, addition of the customized

home exercise program, the patients new knowledge ofjoint protection principles). Her decreased knee painprovided an opportunity for greater tolerance of func-tional activities (eg, work) and the strengthening exer-cises prescribed. Muscles have been described as shockabsorbers54 because muscular contraction has the abil-ity to protect cartilage.40 The ability to effectively engagein a strengthening exercise program, therefore, wasnecessary. As a result, decreased stress on the chondrallesion might have helped diminish pain and future tissuedamage.54

Careful loading (stress) of the lesion must be consideredin light of its potential effects on tissue healing. Evidencesuggests that the articular cartilage response to stress isdependent on delivering the appropriate amount oftissue loading.32,54 Hefti et al8 and Aichroth11 both foundthat the classic medial femoral condyle lesions demon-strated the least evidence of healing over time. These

lesions are located within the intercondylar notch of thefemur (nonweight bearing surface) and thus are sub-ject to less loading over time. Patients with a history ofincreased athletic participation also demonstrateddecreased healing rates of OCD lesions.8 Hefti andcolleagues8 suggested that this may have been the resultof tissue or lesion overload. Therefore, it appears thatcareful and controlled loading of the articular lesionmust be considered given its potential to contribute tohealing during conservative management.32,54

The interventions, other than iontophoresis, utilizedwith this patient were based on clinical decisions that

used the formula stressforce/area as their foundation.30

Interventions were chosen primarily in an effort todecrease the amount of force applied to the tibiofemoraljoint (ie, change in footwear, avoidance of knee exten-sion during first week of treatment, patient educationregarding modification of standing time at work, effectsof increased body weight and strengthening exercises formuscles crossing the joint).

The patient reported a change in her footwear andinitiation of activity modification immediately after theinitial physical therapy intervention. Given the unload-

ing effect that these actions may have had on thetibiofemoral joint, it appears that her early and contin-ued decreases in pain may have been aided, in largepart, by a decrease in the overall force placed on thelesion. Although a centrally mediated analgesic effectfrom the electrical stimulation remains a plausible expla-nation for her early symptom relief, at the 9-monthfollow-up she said that she believed the change infootwear had the greatest overall influence on the suc-cessful resolution of her knee pain.

Linden55 stated that, within the natural progression of

adult OCD, degenerative changes generally occur onlyafter a long asymptomatic period. For example, hedescribed patients with OCD who developed symptomsof degenerative arthritis after nearly 20 years. The focuson joint protection education, therefore, was made toprovide for present symptom management and preven-tive measures against further articular cartilage degen-eration. It was my responsibility to provide the patientwith information that may help to limit further futureinjury to her knee.



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ConclusionAlthough conservative management of OCD at the kneetypically consists of limited weight bearing for 6 to 8weeks and often is not even recommended for adultpatients (20 years), my decision to treat this patientwas based on the favorable conditions8 of her OCDlesion and the specific goals she had for physical therapy.

Therefore, I believe that physical therapists decisionsregarding how to manage adult patients who have adiagnosed osteochondritic lesion of the knee, includingthe selection of specific physical therapy interventions,should be made in light of several factors: (1) the diseaseprocess, (2) patient characteristics (eg, age, health sta-tus), (3) clinical examination findings, (4) diagnosticimaging results, (5) physician consultation, and (6) thepatients goals for therapy. Information obtained fromthe clinical examination and diagnostic image findingsshould be used together to determine those adultpatients with OCD who may benefit from physical ther-apist management. This case illustrates the combination

of current best evidence and the patients individualneeds and expectations from physical therapy whenmaking clinical decisions about care. Future studies toexamine the effects of specific, nonsurgical interventionson adult patients with stable OCD lesions would bebeneficial.

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Physical Therapy Osteocondritis Dissecans

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