Athletes’ knees and OCD: Between ROCK and a hard place

by Benton Heyworth on November 15, 2011

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As more and more children sign up for organized sports, knee injuries such as anterior cruciate ligament (ACL) or meniscus tears have continued to rise. But less well known is osteochondritis dissecans, or OCD – an injury that can have a devastating effect on the knee joint if not diagnosed early and managed properly. Kids’ worlds are turned completely upside down by OCD, when they go from the playing field to crutches.

OCD starts when a small area of bone just under the knee’s smooth cartilage loses some of its blood supply. The starved bone tissue starts to weaken and crumble, and, without this scaffold to support it, the cartilage can weaken as well. Sections of cartilage can even break off as free-floating bodies in the joint space – sometimes with pieces of bone attached to them – leaving behind large defects in the joint’s surfaces.

The damage causes debilitating knee pain, swelling, difficulty walking, and, in some cases, arthritis at an early age. It is somewhat ironic that the most commonly affected population is one of young, healthy kids.

We don’t entirely understand the cause of the condition, though in some instances it may be multi-factorial. However, one clear trend is that we seem to be diagnosing this more often in young athletes participating in sports such as football, basketball, gymnastics, soccer, and lacrosse. This trend speaks to the theory that OCD is a type of overuse injury caused by repetitive micro-trauma to the knee.

We also face a dearth of treatment options for these children. For the moment, we most commonly offer arthroscopic surgery to stimulate the bone to heal itself, to reattach the loose piece, or to transfer cartilage from a healthy non-weight bearing portion of the knee to the area of the defect..

When it comes to developing new options or established standards of care for diagnosing and managing OCD early, however, we face a significant obstacle: While the numbers are on the rise, there simply are not enough patients – a good problem to have, to be sure, but one that prevents us from fully understanding the condition or what we currently do for it. While OCD is common enough to be seen frequently by pediatric orthopedic surgeons, it is not common enough to be studied rigorously by any single center.

X-ray of the knee of an OCD patient, with arrows pointing to tell-tale irregularities in the surface of the joint. (Uniformed Services University/Wikimedia Commons)

Two weeks ago I joined 12 other orthopedic surgeons – largely sports medicine specialists who treat large numbers of young athletes – at the headquarters of the American Association of Orthopedic Surgeons (AAOS) to develop a team approach to answering the most difficult questions about how we care for OCD. As a group, we have come together with a team of musculoskeletal radiologists, physical therapists, and other researchers to form the first major multi-center research organization dedicated to the study of OCD: an organization called Research in OsteoChondritis of the Knee, or ROCK.

Our goal is simple: To try to advance our understanding of OCD enough in the next decade or two – how to better diagnose, treat, and prevent it – to eliminate the significant problems that it currently causes for young athletes.

We spent much of the weekend finding common ground – not easy for any group of 13 surgeons practicing all over the country – on research protocols for future studies and completing studies that are underway so we might better understand this entity. While almost twenty hours in a hotel conference room discussing classification systems, x-rays, and surgical techniques may not be anyone’s idea of a great weekend, hopefully we’re off to a good start in trying to tackle one of the bigger problems we see.

Between our respective institutions, we are confident that we can gather the numbers of patients to rigorously study and understand the biology and natural history of OCD and carry out trials that will improve the ways in which we manage it.

Benton Heyworth, MD, is a surgeon in the Orthopedic Center at Children’s Hospital Boston, where he sees patients for sports medicine, orthopedic trauma and hip-related issues. He is also a member of the hospital’s Orthopedic Clinical Effectiveness Research Center, which aims to improve the quality of life for children with musculoskeletal disorders.

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