Case StudyOsteochondritis Dessicans Master B is a 13-year-old boy who recently presented to the clinic with a one-week history of anterior knee pain and difficulty straightening the knee. Master B did not recall any specific trauma or injury to the knee, but had experienced this pain sporadically in the past few months. This particular bout had however been worse and had lead to difficulty straightening the knee. He was now unable to run and found walking difficult also.
Fragmentation has occurred at the lateral aspect of the medial femoral condyle. A large loose body has separated from the condyle and lies within the intercondylar notch.
Initial examination revealed an antalgic gait with a valgus shift of the right knee in mid stance, reduced knee extension and reduced control of the knee in weightbearing positions. Interestingly, Master B was able to perform a full squat without too much difficulty. Extension range of movement was however limited to -15 by pain and muscle spasm.
There was considerable tension within the hamstrings tendons and posterior capsule, but the patellofemoral joint was unremarkable. Treatment at the time focussed on reducing hamstring spasm and regaining knee extension, which improved to -5 extension within one session.
However, due to the uncommon presentation a set of X-rays was ordered. This revealed osteochondritis dessicans involving the developing medial femoral condyle with a large boney fragment around the lateral aspect of the condyle. Master B was immediately referred to a sports physician who then arranged specialist orthopaedic referral. The likely outcome was to involve surgical intervention to either pin or resect the boney fragment.
A subchrondral bone defect at the medial femoral condyle shows a good cortical margin at its rim, and appears healed. A displaced ossicle lies in the intercondylar notch.
This is an example of physiotherapists as primary contact practitioners detecting an uncharacteristic presentation that is beyond the scope of manual treatment and then arranging appropriate onward referral.
Physiotherapists are well-trained clinicians, who use a battery of diagnostic tests and pattern recognition to determine the source of pain. Clinical reasoning skills are also important in differential diagnosis.
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