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
Common Youth Leg Injuries
Why are Children's Injuries Different to Adults?
Adolescent Leg Injuries
Adolescent injuries differ from adult injuries, mainly because the bones are still growing. The growth plates (physis) are cartilaginous (strong connective tissue) areas from which the bones elongate or enlarge. Repetitive stress or sudden large forces can cause injury to these areas.
In the adolescent leg, common injuries include:
Pain at the bump just below the knee cap (tibia tubercle). Overuse injuries commonly occur here. The tibia tubercle is the anchor point of your mighty quadriceps (thigh) muscles. Because of excessive participation in running and jumping sports, the tendon pulls bone off and forms a painful lump that will remain forever. This type of injury responds to reduced activity and physiotherapy.
More info: Osgood Schlatter's Disease
Pain at the lower pole of the knee cap (patella). Overstraining causes Sinding-Larsen-Johansson disease. Because of excessive participation in running and jumping sports, the tendon pulls bone off the knee cap. This type of injury responds to reduced activity and physiotherapy.
More info: Sinding Larsen Johansson Syndrome
Anterior Knee Pain
Anterior knee pain or patellofemoral syndrome frequently gets passed off as growing pains. Cause of this pain includes overuse, muscle imbalance, poor flexibility, poor alignment, or more commonly, a combination of these. Anterior knee pain is one of the most challenging adolescent knee injuries to sort out and treat. Accurate diagnosis and treatment with the assistance of a physiotherapist with a particular interest in this problem usually resolves the condition quickly.
More info: Patellofemoral Pain Syndrome
The cartilage between the leg bones has a better blood supply and is more elastic in adolescents than adults. As adolescents near the end of bone growth, their injuries become more adult-like. Hence more meniscal and ACL (anterior cruciate ligament) injuries are likely. MCL (medial collateral ligament) injuries result from a lateral blow to the knee. Pain felt on the inner side (medially) of the knee. MCL injuries respond well to protective bracing and conservative treatment.
More info: Knee Ligament Injuries
ACL (Anterior Cruciate Ligament) Injuries
This traumatic knee injury is significant. Non-contact injuries of the ACL are becoming more common than contact injuries of the ACL. Adolescent females are at high risk. Combination injuries with MCL or menisci are common. Surgical reconstruction is needed if the adolescent wishes to continue participating in "stop-and-start" sports.
More info: ACL Injury
Your meniscus is crescent-shaped cartilage between the thigh (femur) and lower leg (tibia). Meniscal injuries usually result from twisting. Swelling, catching, and locking of the knee are common. If physiotherapy treatment does not resolve these damages within six weeks, they may require arthroscopic surgery.
Heel pain is commonplace in young adolescents due to the stresses of their Achilles tendon pulling upon its bony insertion point on the heel (calcaneum). It is a common overuse injury due to excessive training and competition, particularly when loads are increased dramatically in a short period. Diminished flexibility and muscle-tendon strength mismatching may predispose you. Physiotherapy, reduced activity, taping and orthotics are the best ways to manage this debilitating condition for the active young athlete.
More info: Sever's Disease
An ankle sprain is probably the most common injury seen in sports. Ankles sprains involve stretching of the ligaments and usually occur when the foot twists inward. Treatment includes active rest, ice, compression and physiotherapy rehabilitation. With the correct treatment, a low ankle sprain usually improves in two to six weeks. Your ankle physiotherapist should check even simple ankle sprains to eliminate high-ankle sprains. A residually stiff ankle post-sprain can predispose you to several other lower limb issues.
More info: Sprained Ankle
Patellar (kneecap) instability can range from partial dislocation (subluxation) to dislocation with a fracture. Partial dislocation treatment is conservative. Dislocation with or without fracture is a much more severe injury and usually will require surgery.
More info: Patella Dislocation
The separation of a bone from its bed in the knee joint is Osteochondritis Dissecans (OCD). This injury is usually due to one major macro event with repetitive macro trauma that prevents complete healing. This injury is potentially severe. Treatment varies from rest to surgery. An Orthopaedic Surgeon's opinion is vital.
More info: Juvenile Osteochondritis Dissecans (JOCD)
Growth Plate Fractures
A fracture through the growth plate can be a severe injury that can stop the bone from growing correctly. These fractures should be treated by an Orthopaedic Surgeon, as some will require surgery.
An avulsion fracture occurs when a small segment of bone attached to a tendon or ligament gets pulled away from the main bone. The hip, elbow, and ankle are the most common locations for lower limb avulsion fractures in young sportspeople.
Treatment of an avulsion fracture typically includes active rest, ice and protecting the affected area. This active rest period is followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Your physiotherapist should supervise your post-avulsion exercises. Most avulsion fractures heal very well. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. An avulsion fracture to your foot or ankle may require a cast or walking boot.
An excessive gap between the avulsed bone fragment and main bone may not rejoin naturally in rare cases. Surgery may be necessary to reunite them. In children, avulsion fractures that involve the growth plates also might require surgery. All avulsion fractures should be reviewed and managed by your trusted physiotherapist or an Orthopaedic Surgeon.
For more information regarding your youth sports injury, please consult your physiotherapist or doctor.
Youth Leg Injuries
Pelvis & Hip
- Osgood Schlatter's Disease
- Sinding Larsen Johannson Disease
- Patellofemoral Pain Syndrome
- Patella Dislocation
- Meniscus Tear
- Discoid Meniscus
- Osteochondritis Dissecans