Juvenile Osteochondritis Dissecans (JOCD)
What is Juvenile Osteochondritis Dissecans?
Juvenile Osteochondritis Dissecans is a condition of the joint surfaces and underlying bone in people who are still growing. Typically seen in children and young people, JOCD is primarily an active youth person’s condition. Changes in the cartilage and underlying bone lead to pain, alterations in movement and ability to compete in their sport. Although higher activity levels are considered a risk factor, you don’t have to be an athlete to have this condition.
Juvenile Osteochondritis Dissecans Stages
There are four general stages of Juvenile Osteochondritis Dissecans
Stage 1: changes or compression of the bone immediately underlying the cartilage (subchondral bone)
Stage 2: partial separation of the subchondral bone, but no movement away from the cartilage
Stage 3: complete separation of the bone from the cartilage, again with no separation
Stage 4: complete separation of the piece of bone, and it comes away from the remaining bone and floats in the joint cavity
There are a variety of different classification systems for JOCD, but none are widely accepted.
What are the Symptoms of Juvenile Osteochondritis Dissecans?
Each joint in our body has cartilage and subchondral bone, and as such, there are a variety of ways that JOCD presents. Juvenile Osteochondritis Dissecans commonly occurs in the knees (about 95% of cases), hips, ankles, elbows, and collarbones, although they may occur in other joints.
Children and young people will complain of:
- Pain, especially during or after activity
- Reduced joint range of motion
- Crepitus (crunchy or popping noises from joints)
What Causes Juvenile Osteochondritis Dissecans?
There are many theories for what causes Juvenile Osteochondritis Dissecans, but it seems to be many various factors coming together to create the ‘perfect storm’ and produce this condition. Over the years, lots of theories have arisen:
- Genetic susceptibility, where there is a history of Osteochondritis Dissecans in the family or other similar joint conditions
- Repeated microtrauma to the area, sporting populations, are at a higher risk.
- Reduced blood supply to the subchondral bone
- Anatomical variations of knee alignment, meniscus types, blood supply
- Biomechanical (movement) inefficiencies due to obesity, reduced strength, impingement etc.
- Uneven bone growth from anatomical variation or growth plate injury
- Joint instability, either structural or dynamic/functional
- Endocrine (hormonal) changes – vitamin D deficiency, human growth hormone deficiency
How is Juvenile Osteochondritis Dissecans Diagnosed?
There aren’t any valid or specific tests to rule in Juvenile Osteochondritis Dissecans. However, physiotherapists can perform a comprehensive examination to rule out all other options. They look to include or exclude injuries or conditions to the surrounding tissues, including systemic illnesses that manifest as joint pain. Usually, diagnosis is mainly made by a comprehensive interview to understand your symptoms, backed up by imaging, e.g. MRI.
Wilson’s test is one test to examine knees for JOCD, but the reliability and validity of this test are unknown for diagnostic purposes. Wilson’s test may monitor your progression throughout your rehabilitation.
Imaging for Juvenile Osteochondritis Dissecans
If your physiotherapist or GP thinks you might have Juvenile Osteochondritis Dissecans, they will send you for scans. A mix of scans determines if JOCD is present in whichever joint you have pain in because of the different types of tissues they show.
X-rays are usually taken from a variety of views. Typically, images are taken from front to back and the side. Other unique aspects aligned with the natural joint gaps may provide more unobstructed views. These depend on which joint is involved, and your doctor, physio and radiologist will be able to determine if any unique views are needed.
MRI is used to view softer tissue involvement, swelling, bone bruising, and any early-stage changes to the joint surface. There is limited use to determine whether any pieces are ‘free-floating in the joint space. A combination of X-ray and MRI are routine imaging.
MRI image showing an OCD lesion in a knee (OrthoInfo, 2020)
It would be best if you discussed your Juvenile Osteochondritis Dissecans case with your trusted healthcare professional. Would you please book an appointment with your trusted physiotherapist or doctor?
Treatment Options for Juvenile Osteochondritis Dissecans
Treatment depends on the nature of the changes inside the joint. Your age and whether their growth plates have finished growing are just some of the factors. Joints that don’t have any undisplaced pieces are typically conservatively treated. Treatment options include physiotherapy, reduced loading and a graduated return to activity.
For Juvenile Osteochondritis Dissecans lesions that have fragments or pieces that may come loose into the joint space, please consult your Orthopaedic surgeon’s opinion. They will determine if bone pieces need to be removed or put back into their original place. This removal or salvaging might need to happen before any exercise therapy to avoid further irritation to the inside of the joint surfaces.
Treatment plans are bespoke to each individual, so your physiotherapist and sports physician will discuss your options with you if you have an OCD lesion found on imaging.
Unloader braces have been put forward regarding the knee and elbow OCD to promote healing and maintain movement and independence. Other movement aids like crutches, splints, casts, and different types of bracing are options.
What Results Can You Expect from Juvenile Osteochondritis Dissecans Treatment?
Results vary widely depending on what sort of Juvenile Osteochondritis Dissecans lesion you have, and therefore your treatment.
Pain and swelling management, strengthening, restoration of movement, coordination, and balance retraining are vital components of Juvenile Osteochondritis Dissecans treatment. Treatments focus on returning you to the sport or activity of choice. In the case of no fragment or a fragment that hasn’t moved, conservative treatment commences immediately and typically undergo a 3-6 months trial before deciding if a surgical intervention is needed. As stated above, if there is a loose fragment, your surgeon might need to remove this before starting exercise therapy.
There are no established, widely accepted protocols for conservative treatment. The treatment plans are always bespoke to the person and change over time, depending on their progression. Some guidelines help clinicians to guide a return to weight-bearing. These formulate on your clinician’s experience and consensus statements from leaders in the research.
Critical components of rehabilitation base themselves upon a general phased approach. These phases progress under the guidance of your specialist doctors, surgeons, physios and anyone else collaborating on your treatment team. There is no consensus on what factors guide movement between these phases, but radiographic findings and mechanical symptoms impact. Swelling, pain, neuromuscular control, muscle strength and performance, and weight-bearing are all noted influencing factors.
Outcomes vary widely based on the type of surgery you have. Timelines for treatment and recovery of surgical intervention are best sought from your surgeon if you need operative management. Typically, recovery means six weeks on crutches and 6+ months to get back to full function and return to sport. Your healing includes several months of physiotherapy and exercises rehabilitation to restore movement, strength, coordination and balance. The protocol for this rehabilitation is as per conservative management above.
This type of therapy is in its infancy for OCD. Therefore, it is still too early to determine how effective it is in the long term. Researchers have trilled it in knees, elbows and ankles. There are, however, early, promising results. Currently, its primary use is for those people where surgery has been unsuccessful.
Long Term Outcomes
There is some evidence suggesting that children and young people who suffer from OCD lesions develop osteoarthritis at higher rates than the general population. However, there is a lack of good quality, long-term, well-controlled research. It is challenging to stay just how much of an increased risk there is because much of the research doesn’t allow for considerations like other arthritis risk factors, conservative vs non-operative treatment.
A US research group called the ROCK group research Juvenile Osteochondritis Dissecans in the knee. Their research is ongoing, looking into the different types of surgeries and their outcomes, the long term effects of treatment of JOCD and secondary outcomes/complications. More information will be available when they publish their findings.
For more information, Juvenile Osteochondritis Dissecans is a condition that you must discuss with your trusted physiotherapist or doctor.
Common Youth & Kids Sports Injuries
Elite Sports Injury Management
You probably already know that a sports injury can affect not only your performance but also your lifestyle. The latest research continues to change sports injury management considerably. Our challenge is to keep up to date with the latest research and put them to work for you.
How we treated you last year could vary significantly from how we treat you this year. The good news is that you can benefit considerably from our professional knowledge.
What Should You Do When You Suffer a Sports Injury?
Rest from painful exercise or a movement is essential in the early injury stage. "No pain. No gain." does not apply in most cases. The rule of thumb is - don't do anything that reproduces your pain for the initial two or three days. After that, you need to get it moving, or other problems will develop.
Ice or Heat?
We usually recommend avoiding heat (and heat rubs) in the first 48 hours of injury. The heat encourages bleeding, which could be detrimental if used too early. In traumatic injuries, such as ligament sprains, muscle tears or bruising, ice should help reduce your pain and swelling.
Once the "heat" has come out of your injury, you can use heat packs. We recommend 20-minute applications a few times a day to increase the blood flow and hasten your healing rate. The heat will also help your muscles relax and ease your pain. If you're not sure what to do, please call us to discuss your situation specifically.
Should You Use a Compressive Bandage?
Yes. A compressive bandage will help to control swelling and bleeding in the first few days. In most cases, the compressive dressing will also help support the injury as you lay down the new scar tissue. This early healing should help to reduce your pain. Some injuries will benefit from more rigid support, such as a brace or strapping tape. Would you please ask us if you are uncertain about what to do next?
Gravity will encourage swelling to settle at the lowest point. Elevation of an injury in the first few days is beneficial, especially for ankle or hand injuries. Think where your damage is and where your heart is. Try to rest your injury above your heart.
What Medication Should You Use?
Your Doctor or Pharmacist may recommend pain killers or an anti-inflammatory drug. It is best to seek professional advice as certain medications can interfere with other health conditions, especially asthmatics.
When Should You Commence Physio?
In most cases, "the early bird gets the worm". Researchers have found that the intervention of physiotherapy treatment within a few days has many benefits. These include:
- Relieving your pain quicker via joint mobility techniques, massage and electrotherapy
- Improving your scar tissue using techniques to guide the direction it forms
- Getting you back to sport or work quicker through faster healing rates
- Loosening or strengthening of your injured region with individually prescribed exercises
- Improving your performance when you return to sport - we'll detect and help you correct any biomechanical faults that may affect your technique or predispose you to injury.
What If You Do Nothing?
Research tells us that injuries left untreated take longer to heal and have lingering pain. They are also more likely to recur and leave you with either joint stiffness or muscle weakness. It's important to remember that symptoms lasting longer than three months become habitual and are much harder to solve. The sooner you get on top of your symptoms, the better your outcome.
What About Arthritis?
Previously injured joints can prematurely become arthritic through neglect. Generally, there are four main reasons why you develop arthritis:
- An inappropriately treated previous injury (e.g. old joint or ligament sprains)
- Poor joint positioning (biomechanical faults)
- Stiff joints (lack of movement diminishes joint nutrition)
- Loose joints (excessive sloppiness causes joint damage through poor control)
What About Your Return to Sport?
Your physiotherapist will guide you safely back to the level of sport at which you wish to participate. If you need guidance, ask us.
What If You Need Surgery or X-rays?
Not only will your physio diagnose your sports injury and give you the "peace of mind" associated, but they'll also refer you elsewhere if that's what's best for you. Think about it. You could be suffering needlessly from a sports injury. Would you please use our advice to guide you out of pain quicker? And for a lot longer.
If you have any questions regarding your sports injury (or any other condition), don't hesitate to get in touch with your physiotherapist to discuss. You'll find our friendly staff happy to point you in the right direction.
Youth Spinal Pain
Teenager Neck & Back Pain
Teenagers can be particularly vulnerable to back pain, mainly due to a combination of high flexibility and low muscle strength and posture control.
The competitive athlete and most individuals who exercise regularly or maintain fitness and core stability control are less prone to spine injury and problems due to the strength and flexibility of supporting structures. Luckily, issues involving the lower lumbar spine are rare in athletes and account for less than 10% of sports-related injuries. Injuries do occur in contact sports and with repetitive strain sports. Your physiotherapist can assist in the resolution of any deficits in this area.
Sports such as gymnastics, cricket fast bowlers, and tennis have a higher incidence of associated lumbar spine problems related to repetitive twisting and hyper-bending motions.
Spondylolisthesis is a significant concern and needs to be appropriately treated by a physiotherapist with a particular interest in these types of injuries. Luckily, most injuries are minor, self-limited, and respond quickly to physiotherapy treatment.
Common Adolescent Spinal Injuries
Lower Back (Lumbar Spine)
Midback (Thoracic Spine)
Neck (Cervical Spine)
For specific advice regarding youth neck or back pain, please seek the professional advice of your trusted spinal physiotherapist or doctor.