Osteochondritis Dissecans of the Trochlear Groove in Male Soccer Athlete

Michael Boisselle

Pathology and Evaluation I

Dr. Sterner

By Michael Boisselle

Objective: To present a case of osteochondritis dissecans that occurred in a 20-year-old male while on a run. In this case the individual’s lesion was located on the medial aspect of the lateral trochlear groove of his left knee. Background: In this case the individual was not seen or evaluated until one week after he sustained the injury. He walked with an obviously impaired gait with severe pain. He recalled the injury involving a valgus force while stepping off the curb during a run; at the time of injury he heard a “pop”. Assessment of the individual was limited due to the extreme pain when pressure was put on the knee. However, a true positive of Patella Apprehension test was noted, and the extreme pain over the trochlear groove indicated that a MRI must be done to determine the damage done to the knee. Differential Diagnosis: Due to the “pop” the first pathology that came to mind was a subluxed patella. However, with such effusion on the lateral side of knee, an MRI was done and showed signs of patella subluxation as well as a lesion on the trochlear groove that was completely separated from the surface. Treatment: Range of motion exercises were implemented to keep from joint stiffness; the patient performed many open kinetic chain exercises to strengthen the injured legs quadriceps muscles. Uniqueness: Due to the location of the lesion and importance for the individual to play, non-operative measures were taken. However the patient was noncompliant and never listened to medical professionals. Conclusion: The non-compliant athlete has not yet fully recovered after four months, If he had continued to do rehab as instructed and follow the orders of the medical staff he could have potentially been back within 4-6 weeks. Key Words: osteochondritis dissecans, trochlear groove, soccer player, knee injuries, non-surgical treatment

Pathology: A term Konig first used in 1888, “osteochondritis dissecans” described a pathology that led to the formation of loose bodies in the femoral region of the knee, occurring with no evidence of previous trauma. Konig chose this term to refer to an inflammation of the osteochondral joint surface1. Osteochondritis dissecans (OCD) is a lesion of bone cartilage that is characterized by the separation of an osteochondral fragment from the articular surface, an increasingly common cause of knee pain among both adolescence and preadolescence individuals who are skeletally immature, most commonly occurring in males age 10 to 20 years old2,3,4. The pathology involves the progressive stages of an intact lesion to a potentially loose or separated fragment5. Despite the prevalence of this disease, the etiology is still uncertain; some hypothesizes include chronic trauma, ischemia, genetic factors, endocrine related causes, and repetitive microtrauma4,1,2. It has been concluded that in most cases of juvenile OCD high activity levels were recurrent1. OCD is separated into two classes, juvenile and adult, each characterized by the closing of the epiphyses2. OCD can occur at numerous joint articulations, though the femoral condyles are the most common site. More specifically, 75% to 85% of all accounts of OCD of femoral condyles occur at the medial femoral condyle1,4.Fairbank proposed that the medial femoral condyle is the common site of OCD due to the repetitive impingement of the tibial spine on the lateral aspect of the medial femoral condyle during internal rotation of the tibia1. OCD of the lateral femoral condyle can be associated with the reduction of a dislocated patella1. OCD can be divided into stages based on arthroscopic findings (See figure A; Appendix 1)1. This includes: stage I, irregularity and softening of articular cartilage; stage II, articular cartilage breached, definable fragment, not displaced; stage III, articular cartilage breached, definable fragment, displaceable, but attached by some overlying articular cartilage; stage IV, loose body1. Treatment of OCD is controversial in both adult and juvenile OCD when determining whether operative or non-operative treatment is more beneficial. However, any instable lesions in stages III or IV require surgical intervention regardless of age1. In this case the individual has a stage IV lesion on the medial aspect of the lateral trochlear groove. Since this location does not bear the weight of the body, the individual has the opportunity to let the lesion heal without surgical intervention. In doing so he would be able to participate in athletic activity approximately half-way through the season.

Personal Data: This case of osteochondritis dissecans occurred in a twenty-year-old male. The individual is 6 feet tall (182.8 centimeters) and weighs 170 pounds (77 kilograms). As a sophomore at Rowan University, he is an active participant of the Division III soccer program. He is right foot dominant in the sport of soccer. The injury is to the medial aspect of the lateral trochlear groove of the left knee.

History: The athlete recalls the time of injury and mechanism. He emphasizes that he has injured the knee previously during both his junior and senior year of high school; the diagnosis of both injuries was a partial ACL rupture. As for the current injury, the individual was running around the campus on the sidewalk; upon crossing a street, he went to step off of the sidewalk and awkwardly planted his foot off the curb, experiencing what was described as a valgus force that caused his left knee to buckle. After the initial injury he continued for about 100 yards. At that time the pain was too agonizing and he walked the rest of his way. The patient did describe hearing a “pop” at the time of the injury. He went on for a few days without getting evaluated, while keeping an eye on the injury, icing and elevating it throughout the day. He mentions a large amount of swelling as result to the injury. After about one week the pain became so unbearable he couldn’t sleep through the night. He went to the hospital, where he was then referred to a specialist. A week and a half after initial injury he was seen in the athletic training room and evaluated by the staff, from there he was sent for an MRI.

Physical Examination: The individual walked into the athletic training room with a noticeably impaired gait. Observation of the involved knee showed little ecchymosis and no deformity. However, there was a great amount of effusion at the injury site. The individual was severely point tender over the lateral femoral condyle and lateral joint line of the knee. He rated the pain a 10/10, ten being the worst pain he has ever felt. Palpation of the trochlear groove presented the individual with extreme pain. There were severe limitations in the range of motion assessment due to pain. Deficits in strength were about 3/5 for both knee flexion and extension. Circulation and neurological evaluations were all within the normal limits. As each special test was performed, false positives of pain became prevalent and the individual became apprehensive due to pain. Loch Mans was performed with no positive findings. Valgus stress tests were positive for pain due to the pressure put on the lateral aspect of the knee. Varus stress test was also positive for pain but difficult to tell end feel due to the apprehensiveness of the athlete. Patella apprehension test was positive causing extreme pain over the medial patellar retinaculum. This, along with the patient hearing a “pop”, suggests a patella subluxation at the time of injury. Other tests performed could not provide conclusive pathologies due to pain. The athlete was sent to get an MRI for better evaluation.

Results of MRI: The MRI showed that the cartilage of the medial aspect of the trochlear groove on the lateral side had a decent sized lesion in which the lesion is detached from the surface. Also the patella’s posterior surface appeared damaged. The abnormal showing of the posterior surface of the patella indicates that the patella most likely subluxed at the time of the injury.

Diagnosis: The valgus force created while he stepped off the curb caused a patella subluxation, which, in turn, caused a lesion of the cartilage on the femoral trochlear groove. This resulted in osteochondritis dissecans on the trochlear groove. With the MRI results, as well as other assessments performed, I confidently diagnosed the individual with OCD on the trochlear groove that is associated with stage IV lesion.

Treatment: Treatment for adult OCD most commonly involves surgical intervention to promote proper healing to prevent degenerative joint disease at an early age; the adult knee rarely heals from OCD without surgical intervention1,3,5. With OCD there are important factors that must be factored into deciding not to undergo a surgical procedure; this mainly includes the ability of the injured individual to be compliant and stay motivated throughout the lengthy and sometimes frustrating road to recovery1. In this case the individual has chosen the non-operative path to recovery and was able to do so due to the location of the lesion. Immediate treatment for the individual included rest with minimal weight-bearing activities and repetitive ice and elevation until seen by a physician. The individual was told to refrain from any strenuous activity for 4 to 6 weeks and to allow the healing process to run its course. Regardless of instruction by physicians and athletic trainers, the individual continually disobeyed orders not to take part in any running and strenuous activity, further delaying the healing process. There were times during the season that the athletic training staff had to take him away from the field and explain the severity of his injury. Regardless of disobeying orders, the individual continued rehabilitation programs. The rehabilitation program included daily range of motion exercises as well as well as isometric exercises to build up the strength in the injured leg, specifically the quadriceps femoris4. The goal of the rehabilitation was to regain the strength of the quadriceps that atrophied due to the injury; the goal is to bring the injured leg back to within at least 20 percent of the uninvolved leg. Another goal was to bring down the significant amount of effusion until measurements matched that of the non-involved limb. Patient continued to follow treatment for about one month, then stopped doing treatment regularly and continued to disobey orders not to practice or run. Due to the already rare chance of full recovery for adults with OCD and the non-compliance of the individual, he will most likely find himself needing surgical repair.

Criteria for Return: For this individual to return to activity, he most follow and keep up with all rehabilitation programs and listen to medical professionals concerning what to do, as well as what he should not be doing. Along with compliance, before return the individual needs to show that he can perform full ranges of motion with the absence of pain. The swelling of the involved knee must be within proportions to the involved side, as well as the strength of his quadriceps should also be equal bilaterally. After that criterion is meet, he must be able to perform sport specific (in this case soccer) activities without pain and the absence of swelling following activity. The final permission to return to activity relies on diagnostic evidence (MRI) that shows the lesion has healed and or a physician’s clearance for him to return to activity4.

Importance of This Study: OCD is a very important pathology to be familiar with. As an athletic trainer it is important to be able to diagnose injuries as soon as possible to prevent further injury. In the case of juvenile OCD, an early detection of the disease can be the difference between operative and non-operative treatment; this is especially important because, if not diagnosed until after skeletal maturity, the treatment becomes much more complicated. In the case of this individual he had a form of OCD that was not affected by the articulating surface of the tibiofemoral joint; thus the possibility for recovery without surgical intervention would be plausible. This particular case has great importance when evaluating the subject of non-compliant patients. This case exemplifies how important it is to discuss with the individuals the options they have; in this case the option to discuss is whether or not to have surgery. After hearing what is expected of him through the length of the recovery, maybe through careful consideration he would have realized that he has the option to recover without surgical intervention due to the area of the lesion. It would have been possible to heal in as soon as 4-6 weeks if pursuing the non-surgical option properlywhereas the surgical option could take over 16 months to fully recover from depending on method or surgery. However, due to the patient’s noncompliance the healing process was further delayed and will continue to be delayed until proper care is taken.

Conclusion: This was a very unique case of OCD due to the location of the lesion. Because of the location, a pathology that usually needs to be repaired surgically can be given a chance of a full recovery without surgical intervention. However the recovery is very dependent on the athlete’s ability to be compliant. Through this study the most important conclusion is the importance of the athlete-athletic trainer relationship and the ability for athletic trainers to thoroughly discuss the treatment plan with the injured individual. Without the compliance of the athlete, the healing process is prolonged and the individual will be at higher risk of numerous other pathologies.

Appendix 1

Figure A-Staging of osteochondral lesions1.

Reference Page

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