Physical Therapist Management of an Adult With Osteochondritis Dissecans of the

Knee
1. Michael P Johnson
+ Author Affiliations
1. MP Johnson, PT, MS, OCS, is Director of Professional Development, Mercy Rehab
Associates, 1503 Lansdowne Ave, Darby, PA 19023 (USA)
(mjohnson1@mercyhealth.org)

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Abstract
Background and Purpose. Osteochondritis dissecans (OCD) primarily occurs between 10
and 20 years of age. Adult patients (>20 years) tend to respond poorly to nonsurgical
management. This case report describes the physical therapist management of an adult with
OCD at the tibiofemoral joint. Case Description. A 24-year-old woman had insidious onset
of right knee pain. Magnetic resonance imaging confirmed the diagnosis of OCD.
Interventions included iontophoresis, strengthening exercises, and instruction in strategies to
minimize loading across the knee. Outcome. The patient received 5 intervention sessions. 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
the process, including the use of evidence, of making clinical decisions about the physical
therapist management of an adult with OCD.
 Cartilage diseases
 Clinical decision making
 Connective tissue
 Iontophoresis
 Knee injuries
Osteochondritis dissecans (OCD) is the separation of articular cartilage and its adjacent
underlying subchondral bone from the articular surface of a joint. 1 Koenig2 first described this
condition in 1888, initially hypothesizing that it was an inflammatory disease. Later, a lack of
evidence for the presence of an inflammatory process in the region of the articular lesion led
Pappas3 to name the condition “osteochondrosis dissecans.” Although some authors 4 support
this nomenclature, the term “osteochondritis dissecans” is generally used throughout the
literature. The etiology for this type of osteochondral injury is not completely understood and
varies according to different authors. Hypotheses include: (1) trauma from chronic, repetitive
normal loading, (2) ischemia, (3) genetic factors, and (4) endocrine-related causes.2,4–8
Osteochondritis dissecans can occur at many joint articulations; however, it is most common
in the femoral condyles, talar dome, and capitellum.3,7 The femoral condyles are the site for
75% of the lesions.9 The incidence of OCD of the knee is 3 to 6 out of every 10,000 people. 10
It occurs most often between the ages of 10 and 20 years and is twice as common in males as
in females.10,11
Osteochondritis dissecans at the knee can occur along the inferior surface of the patella, the
lateral femoral condyle, or, most commonly, along the medial femoral condyle. Location on
the medial condyle accounts for approximately 75% to 85% of all femoral lesions. 3,8 These
lesions are typically located along the lateral aspect of the medial condyle within the
intercondylar groove11; however, they can extend more medially along the weight-bearing
surface of the condyle (Fig. 1). Lesions on the medial femoral condyle tend to be located
more anteriorly compared with those on the lateral condyle. 12,13 Hughston et al13 used a lateral
radiograph of the knee to examine anterior or posterior positioning of OCD lesions. They
characterized lesions as: (1) located directly distal to a line drawn parallel to the posterior
cortex of the femur or (2) lying posterior to that line. The location of the lesion determined
when during the knee range of motion (ROM) it was engaged by the tibia (Fig. 2).

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;53:440–
447.

Figure 2.
Areas used to define the location of osteochondritic lesions on the lateral radiograph using a
reference line drawn parallel to the posterior cortex of the femur. The parameters of motion
described indicate the ranges in which the femoral lesion is engaged by the tibia. Reproduced
with permission from Hughston JC, Hergenroeder PT, Courtenay BG. Osteochondritis
dissecans of the femoral condyles. J Bone Joint Surg Am. 1984;66:1340–1348.
Sanders and Crim stated that “knowing when to prescribe conservative versus surgical
therapy requires staging of the lesion.” 4(p356) Many diagnostic imaging methods (eg,
radiography, magnetic resonance imaging [MRI], technetium 99m pyrophosphate joint
scintigraphy, bone scans), as well as arthroscopic examination, have been used in an attempt
to stage or classify osteochondral lesions.4,9,14,15 The stages (typically 3 or 4 levels) represent a
continuum of tissue degeneration leading to complete disruption and instability of the lesion
(loose body). Originally, staging was determined based on radiographic findings. 16 Currently,
MRI appears to be the preferred choice for detection of this type of chondral injury 4,9,15 and
for determining a lesion's stability.15,17 In 2001, Sanders and Crim,4 in their review of
osteochondral injuries, described one of the most commonly used MRI staging schemas
(Table). This schema (5 stages), along with a comparative radiographic schema, 16 describes
common imaging findings associated with OCD lesions (more stable=stages 1 and 2, less
stable=stages 3 and 4). Unstable osteochondral lesions most often require surgical
intervention.5,7,9,18 In an attempt to specifically identify unstable lesions, De Smet et al 17
described the use of 4 findings (consistent with stage 3 and 4 lesions) on MRI to predict
lesion stability (n=31 with lesion on the femoral condyles, mean age=25.7 years). They
reported 97% sensitivity and 100% specificity using this method, noting that the most
common finding associated with instability was the presence of a high signal intensity line
underneath the OCD lesion.
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Table.
Staging of OCD Lesions Using Radiographic and Magnetic Resonance Imaging (MRI)
Findingsa
A variety of surgical methods exist for the management of articular cartilage lesions at the
knee, such as OCD. These include the use of arthroscopic lavage or debridement, radio
frequency energy, bone drilling, osteochondral autografts or allografts, internal fixation of
bone fragments, and autologous chondrocyte implantation (ACI). 18 Rehabilitation following
surgical intervention for chondral lesions of the knee, which depends on the type of procedure
used, generally includes limited weight bearing (4–6 weeks), active and passive ROM
exercise, isometric strengthening exercises of the quadriceps femoris muscle, and weight-
bearing and non–weight-bearing exercises through a limited arc of motion. 18,19 The reader is
referred to Sellards et al18 and Irrgang and Pezzullo19 for more in-depth information regarding
both surgical management and postsurgical rehabilitation of chondral lesions. Pappas 3
developed a classification schema for OCD that was based on outcomes. His classification
was determined according to age categories, based primarily on skeletal maturation: category
I=girls up to 11 years of age and boys up to 13 years of age, category II=girls between 12 and
20 years of age and boys between 14 and 20 years of age, and category III= patients 20 years
of age or older.
Patients in categories I and II were considered skeletally immature, generally having open
epiphyseal plates resulting in continued musculoskeletal growth. Patients in category III were
considered skeletally mature, with closed epiphyseal plates. Pappas 3 and other authors8,9,12,20
contended that the prognosis for healing of symptomatic lesions in adult, skeletally mature
patients (>20 years of age) without the assistance of surgical intervention is poor. Hinshaw et
al9 suggested that symptomatic OCD lesions on the femoral condyles most often require
surgery in adult patients to promote healing. In a multicenter, retrospective study, Hefti et al 8
found improvements in knee outcomes after both conservative and surgical management with
patients who still had an open epiphysis compared with those who were skeletally mature.
Conservative management for juvenile and adult patients with stable lesions may consist of:
(1) non–weight bearing for 6 to 8 weeks, 5,20 followed by restricted sports and other activities
for 6 weeks5,7,20,21; (2) knee immobilization5; (3) daily ROM exercises5; and (4) isometric
strengthening exercises.5 A return to normal activities is advocated only after clinical and
diagnostic (MRI, radiograph) evidence indicates that the lesion has healed. 5 I found only 2
articles5,8 that listed interventions used in the conservative management of adult patients with
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 lesion are considered important prognostic
variables, other factors need to be taken into account, such as the size 22 and location8,11,12 of
the lesion, when making the clinical decision about how to effectively manage an adult
patient with OCD of the knee. In addition to age, Hefti et al8 found better outcomes with
conservative management on follow-up examination (mean=4 years after intervention,
range=1–20 years) in patients (n=79) who had “favorable” conditions at the knee during
initial examination. According to Hefti et al, “favorable” conditions include all 3 of the
following findings: (1) no to moderate joint effusion, (2) fragment diameter ≤20 mm, and (3)
no gross dissection (instability) of the lesion seen with diagnostic imaging. The sample in this
study consisted primarily of children (mean age=13 years 3 months). Some of those receiving
conservative management (n=154) who had “favorable” conditions at the knee, however,
were adults, as defined by a closed epiphysis.
Conservative management of adult patients (>20 years) with OCD of the knee is rarely
recommended in the literature.3,5,9,20 Evidence suggests, however, that some adult patients
with OCD may benefit from physical therapist management. The purpose of this case report
is to describe and discuss the examination, evaluation, and decisions related to physical
therapist management of an adult with OCD at the tibiofemoral joint.
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Case Description
History
The patient was a 24-year-old woman with a 1-month history of intermittent right knee pain.
Her knee pain increased rapidly within 1 week, which she associated with an increase in
work-related activities. She was a cardiac intensive care nurse and had been expected to work
12-hour shifts requiring prolonged lower-extremity weight-bearing activities. An evaluation
by an orthopedic physician shortly after the onset of symptoms resulted in a prescription for
Celebrex* to reduce pain and inflammation and a reduction in the length of her work shifts
from 12 to 8 hours. The patient reported that these measures halted the progression of the
right knee pain, but her symptoms persisted 1 month later. Radiographs revealed no bony or
soft tissue abnormalities, whereas MRI showed an absence of marrow edema and subtle
changes in the subcortical marrow beneath the inner weight-bearing surface of the medial
femoral condyle (inferocentral). This finding was consistent with a stage 2 osteochondral
lesion. The patient was subsequently referred by her orthopedic physician for physical
therapist examination and intervention with a diagnosis of OCD of the right knee.
The patient reported that, before the onset of symptoms, she was able to work a 12-hour shift
and walk recreationally 3.2 to 4.8 km (2–3 miles) an average of 3 to 4 days a week. At the
time of the initial physical therapy visit, she said she could work a maximum of 8 hours and
was unable to walk regularly for exercise because of continued right knee pain. She also said
that she was unable to go up or down stairs, kneel on the front of her knee, sit for more than
20 minutes, or drive a car without an increase in pain. The Single Assessment Numeric
Evaluation (SANE)23 was used to assess function of her knee, which she rated as 55% of
normal. The SANE is a self-report measure that requires the patient to rate the present level
of function on a numeric scale from 0 to 100 (100=normal function). The score represents a
simple, quantitative outcome measure that captures the patient's own perception of function.
This scale has been validated against a modified Lysholm knee score, 24 a functional
questionnaire that incorporates a numeric activity score (r=.58–.87).
The patient described her symptoms as general aching along the anteromedial aspect of the
right knee. The knee was pain-free in the morning, but her symptoms slowly increased
throughout the day. Rest (non–weight bearing) and the use of ice were effective for
temporarily decreasing and controlling knee pain. At the time of the initial examination, she
stated that her pain was 1 out of 10 on an 11-point numeric rating scale (NRS) (0=“no pain”
and 10=“the most excruciating pain you have ever felt”). 25 She reported that her knee pain
increased to 10 during prolonged standing and walking, especially by the end of her work
shift. The test-retest reliability (Pearson r) of the 11-point NRS for pain has been estimated to
be .67 to .96.26 Von Korff et al25 reviewed literature related to the use of this NRS in patients
with acute, chronic, and postoperative pain and concluded that it has acceptable validity and
sensitivity to change.
The patient reported a medical history that included a previous episode of right knee pain
(approximately 5–6 years earlier) that resolved without medical intervention, migraine
headaches, polycystic ovary disease, cardiovascular hypertension, von Willenbrand disease (a
common hereditary bleeding disorder with predominantly mild clinical symptoms), and a
family history of OCD (sister). She said she took 3 prescription medications before her
course of physical therapy: Accupril* to decrease blood pressure, Celebrex for pain and
inflammation, and Loestrin* for birth control.
The patient did not smoke or drink and planned to be married in 2 months. Her goals for
therapy included: (1) avoiding surgery, (2) returning to work at full capacity with minimal
knee pain, and (3) walking down the aisle at her wedding with no knee pain wearing high-
heeled shoes. She was particularly concerned about not losing any further work time because
of a need to save money for her upcoming wedding.
Examination
Observation.
The patient had an endomorphic body type 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 alignment abnormalities were noted. No joint swelling or effusion was observed in
either knee.
Range of motion.
Passive and active knee flexion and extension, measured with the patient in a supine position,
were within normal limits bilaterally.27 Pain was reproduced with end-range overpressure
during both extension and flexion testing of the right knee. The patient reported greater pain
with passive knee extension than flexion.
Muscle performance.
Manual muscle testing was performed in accordance with the manual muscle testing
procedures described by Kendall et al.28 The patient's quadriceps femoris and hamstring
muscles were rated “Normal” for the left knee. Both muscles were rated “Fair” for the right
knee. She reported anterior joint pain during resistance testing of the right knee, but did not
describe pain arising from the tendon or muscle bellies of the quadriceps femoris and
hamstring muscles on the right leg. It was plausible that her inability or unwillingness to
generate normal contractile force was the result of pain rather than of the presence of true
muscle weakness.
Muscle length testing also was performed according to procedures described by Kendall et
al.28 Testing revealed no length restrictions of the quadriceps femoris, hamstring, tensor
fasciae latae/iliotibial band, gastrocnemius, or soleus muscles in either lower extremity. This
finding suggested that limitations in muscle length were not contributing to abnormal forces
or loads at the lower extremity during activity. Although some information about muscle
length can be inferred from a ROM assessment (ie, hip adduction and tensor fasciae
latae/iliotibial band), this assessment cannot provide information about the length of the
hamstring muscles, for example. In addition, proper examination of muscle length requires
standardized testing methods that are not equivalent to those used for ROM measures.
Special tests.
All special tests were performed as described by Magee.29 The patient demonstrated no
abnormalities with neurological testing, including sensory, dermatome, and myotome
screening exams.
Ligamentous stability tests were performed on both knees. Varus and valgus stress tests
performed at 0 degrees and 30 degrees were negative. Lachman and anterior and posterior
drawer tests revealed no apparent cruciate ligament insufficiencies. Meniscal integrity was
not tested during the examination because the patient reported increased pain when initially
attempting either the McMurray or Apley compression tests. The patellar grind test, however,
caused no increased pain.
Gait.
The patient's gait pattern suggested a painful right lower extremity. Observed deviations from
normal included decreased stance time and heel-strike and limited knee ROM during the
swing phase. The patient avoided full knee extension during swing, which limited heel-
strike.30
Palpation.
Palpation was performed with the knee flexed at 45 degrees to expose the area where the
lesion was located according to the MRI report. She reported mild tenderness along the
medial femoral condyle on the left knee (rated as 2/10 pain), but more point tenderness was
noted with direct palpation to the inferocentral medial femoral condyle on the right knee
(rated as 8/10 pain). She reported no specific tenderness with palpation along the joint line
medially, laterally, or posteriorly on the right knee.
Evaluation
The key examination findings included decreased tolerance to weight bearing activities,
stance time, and terminal knee extension during gait, as well as increased pain with passive
overpressure into knee extension and palpation along the anteromedial right femoral condyle.
These findings led to the hypothesis that the patient's functional limitations were associated
with the loading of abnormal tissue (stage 2 osteochondral lesion via MRI findings) along the
weight-bearing surface of the condyle. Considering the diagnostic imaging and clinical
findings, I thought that the patient's lesion was located anteriorly on the weight-bearing
surface of the condyle. Her pain was reproduced most intensely during passive knee
extension (lesion engaged13) and direct palpation to the area. This was consistent with her
unwillingness to fully extend the knee while walking and self-reports of pain mostly with
prolonged standing (knee in relative extension) and walking.
I determined that the patient had impaired muscle performance and motor function associated
with localized inflammation and connective tissue dysfunction on the articular surface of the
right medial femoral condyle. The diagnostic classification was Pattern 4D, “Impaired Joint
Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With
Connective Tissue Dysfunction” in the Guide to Physical Therapist Practice.31 Despite the
evidence suggesting the lack of an inflammatory process associated with OCD, 3 I could not
be certain that a localized inflammatory process, such as synovitis, was not active in her knee
because of recent tissue overuse.32
A paucity of literature exists to guide clinicians in physical therapist management for an adult
with OCD of the knee. Although some authors 3,5,8,22 report that conservative management of
an adult is not prudent, others 4,11 encourage the inclusion of age, characteristics of the lesion
(size, location, stability) as determined with diagnostic imaging, and symptoms present when
making a decision about nonsurgical care.
Consultation with the orthopedic physician confirmed that the lesion was relatively small
(<20 mm) and stable (stage 2) according to MRI findings. The physical therapist examination
and MRI findings indicated that my patient had “favorable” conditions 8 for conservative
management. These conditions included: (1) no swelling or joint effusion, (2) lesion size <20
mm, and (3) no gross dissection (instability) of the lesion. Consultation with the patient
revealed her strong desire to pursue nonsurgical management and a willingness to adhere to
intervention. Her medical comorbidities were not considered to be complicating factors for
physical therapy intervention because of appropriate medical management. The patient's age,
diagnostic image findings (stage 2 “stable” lesion), clinical presentation (“favorable
conditions” for nonsurgical management), and her specific goals for therapy given her present
life circumstances (the need to continue working and avoid surgery due to her upcoming
wedding) led me to believe that physical therapy intervention was warranted.
A review of the literature revealed no studies that specifically addressed the use iontophoresis
for patients with OCD of the femoral condyles. Many authors, 33–37 however, have reported the
effects of anti-inflammatory medication delivery via iontophoresis in patients with a variety
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 and Hasson et al37 reported that the use of iontophoresis with
dexamethasone phosphate (DEX-P) reduced pain and improved early tolerance of a
therapeutic exercise program. Therefore, I made the decision to use iontophoresis with DEX-
P as a part of the intervention plan based on this evidence. Other interventions were chosen in
an effort to minimize stress to the osteochondral lesion.
Intervention
The patient participated in 5 physical therapy sessions at a frequency of 1 to 2 visits per
week. Interventions to address the patient's complaints and impairments began on the initial
visit. The treatment addressed right knee pain and provided the patient with strategies to
decrease loading across the right knee. Iontophoresis was performed using an Iomed Phoresor
II unit† with DEX-P (4 mg/mL solution) applied locally over the right anteromedial 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 purpose for the right knee position was to
expose the site of the lesion on the anteromedial femoral condyle. Before the application of
iontophoresis, moist heat was applied to the anterior knee for 5 minutes to hydrate the skin in
an effort to aid drug delivery to the subcutaneous tissues. 38 Palpation confirmed the site of
tenderness and a small Iogel electrode † was placed over this site. This served as the active
electrode (anode). A dispersive electrode (cathode) was placed approximately 6 to 8 in (15.2–
20.3 cm) distally on the medial calf. The skin was cleaned at both sites with rubbing alcohol
prior to the application of electrodes.

Figure 3.
Iontophoresis treatment applied to the right anteromedial femoral condyle with the patient
seated in a supported, long-sitting position and the knee flexed to expose the lesion site.
The iontophoresis consisted of a 1.5-mA current, determined by patient comfort, applied for
approximately 27 minutes to achieve a dosage of 40.0 mA·min. The dosage was consistent
with that recommended by Costello and Jeske.39 Upon completion of the iontophoresis, the
skin under the active and dispersive electrodes was examined for any abnormal reactions to
the direct current stimulation. No abnormalities in the skin condition beyond mild erythema
were noted. The active electrode was then resecured with tape and the patient was instructed
to leave it in place for 8 to 12 hours as tolerated. The purpose for this was to promote
continued diffusion of the DEX-P medication via the reservoir effect mechanism of the skin.38
The patient then was instructed in joint protection strategies to decrease loading across the
right tibiofemoral joint. First, the patient was encouraged to use cushioned footwear (ie,
running shoes) to limit ground reaction forces at the knee. The patient had previously worn
clogs at work, which had a firm sole and minimal foot control through the upper shoe.
Second, she was instructed to avoid end-range knee extension, including during the gait
cycle, because this position most effectively engaged the lesion. In particular, I made a
conscious decision to avoid correction of her gait deviations (limited knee extension, stance
time and heel-strike on 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 right
tibiofemoral joint. The patient, however, was reluctant to use an assistive device and decided
instead to initiate the first 2 strategies. We agreed to discuss using an assistive device again if
her pain did not improve within the first week of treatment.
A home exercise program was initiated to address the decreased muscle performance of the
right lower extremity. The exercises included modified heel slides and modified straight-leg-
raising exercises. Modified heel slides (30°–90°) were used to promote pain relief and tissue
healing through increased synovial fluid diffusion. Range of motion limits at the knee were
used to avoid stress to the lesion site. Modified straight-leg-raising exercises were performed
with the knee held in approximately 30 degrees of flexion. Single-plane hip flexion (in a
supine position), extension (in a prone position), abduction (in a left side-lying position), and
adduction (in a right side-lying position) were performed within full available hip ROM for 2
sets of 10 repetitions each. These exercises were chosen to strengthen the 2-joint muscles that
cross the hip and knee joints, to allow for improved load attenuation by these muscles (ie,
rectus femoris, hamstring group, gracilis, and tensor fasciae latae/iliotibial band). 28 The
decision to perform these exercises with the knee fixed in 30 degrees of flexion was an effort
to protect the OCD lesion from further loading while initiating strengthening exercises on day
1 of her intervention.
The patient reported a 50% improvement in her symptoms by the second visit, which
occurred 5 days after the initial examination. Given the rapid change in her right knee pain at
that time, I concluded that the need to consider using an assistive device was no longer
warranted. The second and third visits included application of iontophoresis (as described
previously), review of the home exercise program, and continued monitoring of right knee
symptoms and joint protection strategies.
On the fourth visit, 11 days after her initial visit, the patient reported minimal, intermittent
right knee pain (0–1/10) and increased tolerance of all activities. She, however, was still
working an 8-hour shift (versus a 12-hour shift before injury) and had not yet resumed her
regular walking program. The intervention for this visit remained iontophoresis with DEX-P
to the right knee, monitoring of her home exercise program (with an increase to 3 sets of 15
repetitions for all exercises as tolerated), and consultation regarding continued importance of
joint protection. Re-examination of gait revealed a more normal gait pattern, with minimal
pain noted during either the right lower-extremity stance or heel-strike phases. We discussed
a plan to progress her exercise program next visit and began discharge planning.
The patient missed a visit and returned for her fifth and final visit 10 days after the fourth
visit. She reported continued improvement in right knee pain (pain rating 0/10) and functional
activity tolerance, noting an ability to resume walking her dog for short distances (½–1 mile)
without increased knee pain. She reported minor “fatigue” in the right lower extremity at the
end of her 8-hour workday. Iontophoresis was discontinued given her 0/10 pain rating
maintained over a 10-day period. A full re-examination was performed and a decision for
discharge was made in agreement with the patient. Her home exercise program was modified
to include strengthening exercises for the muscles about the hip, knee, and ankle that required
movement of the tibiofemoral joint. These exercises included modified wall slides (20°–90°)
and modified active knee extension (90°–20°) in an effort to promote improved strength and
endurance in knee extension through a greater ROM while still avoiding excessive loading to
the OCD lesion. Patient education during this last visit included a final review of joint
protection strategies at the right tibiofemoral joint and discussion of the importance of
integrating regular strengthening exercises into her daily routine as a long-term method to
protect the joints of the lower extremity.40,41

Outcomes
The patient progressed well throughout her course of physical therapy. Her right knee pain, at
worst, had decreased by 50% (5/10 versus 10/10) by the second visit, it was rated as 0/10 to
1/10 (on average) by the fourth visit, and she experienced no pain with any functional
activities at discharge. She reported only mild tenderness along the anteromedial femoral
condyle on the right knee (pain rating 4/10) with direct palpation to the area. Upon discharge,
ROM at the right tibiofemoral joint remained within normal limits, and no pain was noted
with passive end-range flexion or extension overpressure to the joint. Her muscle strength
was rated as “Normal” for both the right knee flexors and extensors, although she did
describe “fatigue” in the right lower extremity after a full day of work (8 hours). She
demonstrated no observable gait deviations during ambulation, noted the ability to walk her
dog for ½ to 1 mile without difficulty, and reported a 95% rating of function (SANE score).
Although the patient's work status continued with a limited 8-hour shift, she reported no pain
throughout the work day and was planning to resume her normal 12-hour shift within the 2
weeks following discharge from physical therapy.
At the 9-month follow-up (from initial examination), the patient reported “good” right knee
function (95% SANE score) with all activities and no pain (0/10). She had been working 12-
hour shifts consistently for more than 6 months 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-up MRI, which had been scheduled 1 year after the initial MRI; therefore,
no comparative imaging was available to assess healing of the lesion.

Discussion
This case report focused on the physical therapist management of an adult (>20 years) female
patient with OCD of the right knee. She received physical therapy intervention that included
iontophoresis with DEX-P, strengthening and ROM exercises that were modified to limit
stress to the lesion, and patient education on joint protection strategies. Despite
recommendations against conservative management of adults with OCD 3,5,9,20 and limited
guidance from the literature regarding specific interventions5,8 for this population, the patient
made excellent improvement in her impairments and functional limitations after a relatively
short course of treatment.
Some authors have argued that several factors are responsible for the increased potential of
DEX-P diffusion into the underlying tissues with iontophoresis: polarity of the active
electrode,42–45 localized cutaneous blood flow,43,46 pH level in the skin,47 and current
intensity.43 Although use of the anode as the active electrode was originally posited by Glass
et al,48 many authors42–45 have recently provided persuasive arguments for the use of the
cathode. At the time I treated this patient, there were discrepancies in the literature and
among the clinical pharmacy staff at my facility regarding use of the anode or the cathode as
the active electrode with DEX-P. Based on current evidence, however, my facility has been
using the cathode consistently as the active electrode when providing iontophoresis of DEX-P
for the past 4 years.
Early work by Singh and Roberts,46 using salicylic acid with rats, suggested that increased
cutaneous blood flow aided clearance of the solute from the skin. Although little direct
evidence that this effect exists in humans, it is credible to suggest that using thermal
modalities before or after iontophoresis may diminish the reservoir of medication in the skin
available for diffusion to deeper tissues. Anderson et al 43 also hypothesized that increased
cutaneous blood flow, resulting from high-current iontophoresis (1.5–4.0 mA), may aid
clearance of DEX-P, resulting in lower penetration of the drug into subcutaneous tissues.
Recent studies44,45 have shown an absence of DEX-P in the synovium and local venous blood
after the application of iontophoresis delivered at a 4.0-mA current. These findings may
suggest: (1) a lack of effective DEX-P delivery into the subcutaneous tissues or (2) that the
amount of drug delivered was at a level below detection by the methods used in these studies.
Considering the parameters under which my patient received iontophoresis of DEX-P, it is
reasonable to suggest that, in light of recent evidence, delivery of DEX-P into the target tissue
was minimal and unlikely to account for her pain relief. The application of transcutaneous
direct-current electrical stimulation during iontophoresis, however, may have been partially
responsible for her early pain relief.
Many authors49–52 have studied the effects of transcutaneous electrical nerve stimulation
(TENS) on pain relief in human subjects. Although some authors demonstrated that high-
frequency stimulation had the best effect on a subject's perception of experimentally induced
pain,50–52 others described how both high- and low-frequency applications of TENS could be
effective for pain relief.49,53 In a recent review of nonpharmacological treatments for
musculoskeletal pain, Wright and Sluka53 reported evidence that TENS improves joint
function in patients with rheumatoid arthritis. These authors, along with Ulett et al,49 also
reported on the effectiveness of both high- and low-frequency TENS (ie, electroacupuncture)
to inhibit pain through centrally mediated responses in animals and human subjects.
Iontophoresis was delivered to the anteromedial, right knee of my patient through direct-
current (low-rate) stimulation for a period of 20 to 25 minutes per treatment session. These
parameters, although not identical to other forms of TENS commonly used to achieve
analgesia, are similar to low-frequency electroacupuncture (2 Hz, 30 minutes). 49 It appears
reasonable, therefore, to suggest that her early decreases in pain may have been aided, in part,
by the current application from the phoresor unit during treatment application.
It is also possible that the early decrease in symptoms may have been the result of factors
other than, or in addition to, the application of electrical stimulation (eg, a change in
footwear, addition of the customized home exercise program, the patient's new knowledge of
joint protection principles). Her decreased knee pain provided an opportunity for greater
tolerance of functional activities (eg, work) and the strengthening exercises prescribed.
Muscles have been described as “shock absorbers”54 because muscular contraction has the
ability to protect cartilage.40 The ability to effectively engage in a strengthening exercise
program, therefore, was necessary. As a result, decreased stress on the chondral lesion might
have helped diminish pain and future tissue damage.54
Careful loading (stress) of the lesion must be considered in light of its potential effects on
tissue healing. Evidence suggests that the articular cartilage response to stress is dependent on
delivering the appropriate amount of tissue loading.32,54 Hefti et al8 and Aichroth11 both found
that the “classic” medial femoral condyle lesions demonstrated the least evidence of healing
over time. These lesions are located within the intercondylar notch of the femur (non–weight
bearing surface) and thus are subject to less loading over time. Patients with a history of
increased athletic participation also demonstrated decreased healing rates of OCD lesions. 8
Hefti and colleagues8 suggested that this may have been the result of tissue or lesion
overload. Therefore, it appears that careful and controlled loading of the articular lesion must
be considered given its potential to contribute to healing during conservative management.32,54
The interventions, other than iontophoresis, utilized with this patient were based on clinical
decisions that used the formula stress=force/area as their foundation.30 Interventions were
chosen primarily in an effort to decrease the amount of force applied to the tibiofemoral joint
(ie, change in footwear, avoidance of knee extension during first week of treatment, patient
education regarding modification of standing time at work, effects of increased body weight
and strengthening exercises for muscles crossing the joint).
The patient reported a change in her footwear and initiation of activity modification
immediately after the initial physical therapy intervention. Given the unloading effect that
these actions may have had on the tibiofemoral joint, it appears that her early and continued
decreases in pain may have been aided, in large part, by a decrease in the overall force placed
on the lesion. Although a centrally mediated analgesic effect from the electrical stimulation
remains a plausible explanation for her early symptom relief, at the 9-month follow-up she
said that she believed the change in footwear had the greatest overall influence on the
successful resolution of her knee pain.
Linden55 stated that, within the natural progression of adult OCD, degenerative changes
generally occur only after a long asymptomatic period. For example, he described patients
with OCD who developed symptoms of degenerative arthritis after nearly 20 years. The focus
on joint protection education, therefore, was made to provide for present symptom
management and preventive measures against further articular cartilage degeneration. It was
my responsibility to provide the patient with information that may help to limit further future
injury to her knee.

Conclusion
Although conservative management of OCD at the knee typically consists of limited weight
bearing for 6 to 8 weeks and often is not even recommended for adult patients (>20 years),
my decision to treat this patient was based on the “favorable” conditions 8 of her OCD lesion
and the specific goals she had for physical therapy. Therefore, I believe that physical
therapists' decisions regarding how to manage adult patients who have a diagnosed
osteochondritic lesion of the knee, including the selection of specific physical therapy
interventions, should be made in light of several factors: (1) the disease process, (2) patient
characteristics (eg, age, health status), (3) clinical examination findings, (4) diagnostic
imaging results, (5) physician consultation, and (6) the patient's goals for therapy.
Information obtained from the clinical examination and diagnostic image findings should be
used together to determine those adult patients with OCD who may benefit from physical
therapist management. This case illustrates the combination of current best evidence and the
patient's individual needs and expectations from physical therapy when making clinical
decisions about care. Future studies to examine the effects of specific, nonsurgical
interventions on adult patients with stable OCD lesions would be beneficial.

Footnotes
 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
20–23, 2002, Boston, Mass.

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

Iomed Inc, 2441 South 3850 West, Ste A, Salt Lake City, UT 84120.
Received September 7, 2003.
Accepted December 13, 2004.
Physical Therapy

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