Ross Hauser, MD; Danielle Matias, PA-C; Demi Foster, APRN

In this article, we will cover research on Prolotherapy and treatment of Osteochondritis dissecans in youth athletes as a means to help non-surgically accelerate healing. The main focus of this article will be on knees and elbows.

If you are reading this article, you are likely the parent of a teenage athlete who is trying to stay in his/her sport(s). Your child has been diagnosed with Osteochondritis dissecans. The treatment you are being recommended includes weeks of inactivity and rest. You ask about physical therapy, but are told that PT does not really help cartilage reattach to the bone. You are told that only “conservative treatment,” resting or stopping all activities for a prolonged time, or surgery can be used. When you explore more about the surgical aspects, you find out that while the surgery can help, it does not prevent the recurrence of your child’s Osteochondritis dissecans.

You may be struggling with the advice to have “patience” and with your desire to help your athlete get back to their game. What are your options? One option is to research and find answers. We hope to help you with that here.

Case Presentation: Osteochondral Defect in an Adolescent Athlete

Presented by Danielle R. Steilen-Matias, MMS, PA-C

Patient Background

The patient is a 14-year-old male elite soccer player. He has been playing soccer since the age of two and is already attracting attention from professional teams. Despite his promising athletic career, he was diagnosed with an osteochondral defect in his knee. By the time he arrived at our clinic, he had already completed all recommended treatments, including physical therapy and several months of rest, as advised by his local orthopedic specialist. Unfortunately, his condition had not improved. Conservative measures such as continued rest and playing soccer with a knee brace had also failed to resolve his symptoms, which brought him to us.

Failure of treatment and Ligamentous instability of the knee

An osteochondral defect (OCD) involves injury to the bone and the overlying cartilage. In some cases, a fragment of bone and cartilage may break off. When conservative treatments—such as rest and physical therapy do not lead to improvement, whole knee instability should be the focus of treatment and not solely on the area affected by the osteochondral defect.

The knee is stabilized by ligaments, tough connective tissue that holds the bones together. If these ligaments become overstretched and lose their elasticity, they can no longer maintain the joint’s stability. This increased laxity puts additional stress on the bone, meniscus, and cartilage, potentially worsening the underlying defect.

Clinical Evaluation and Findings

A dynamic ultrasound examination was performed to assess the medial and lateral aspects of the knee, specifically evaluating for medial collateral ligament (MCL) and lateral collateral ligament (LCL) laxity or tears. The patient’s medial knee, including the MCL, appeared stable and tight upon valgus stress testing. However, on the lateral side, there was significant ligamentous laxity, as indicated by a positive varus stress test. This area of instability corresponded to the site of the patient’s OCD.

Initial motion X-rays showed that, despite open growth plates consistent with his age, there was a noticeable defect on the lateral side of his femur—described as appearing as though a “bite” had been taken out of the bone. This confirmed the diagnosis of an osteochondral defect.

Treatment Plan

Given the combination of OCD and lateral knee instability, a treatment plan was developed that included dextrose prolotherapy and platelet-rich plasma (PRP) therapy. Dextrose prolotherapy is particularly effective for tightening and strengthening ligaments, thereby restoring joint stability. PRP therapy was used to harness the patient’s own growth factors to help fill in the defect. It was determined that PRP alone would not have sufficed due to the presence of lateral knee instability; addressing both the defect and the instability was essential for a successful outcome.

Follow-Up

After a few treatment sessions, follow-up X-rays revealed that the osteochondral defect had decreased in size, though it was not yet fully healed. Ultrasound examination also showed that lateral knee instability was improving, though not completely resolved. The patient’s local orthopedic specialist reviewed parallel imaging and agreed with our assessment that the defect was indeed filling in and that the patient was making good progress after a couple of treatments.

Despite the improvement, the patient was not cleared to immediately return to full soccer activity. A gradual return to sports and physical activity was recommended to prevent reinjury, which is especially important for young athletes. The patient’s recovery was further supported by the fact that it was not his soccer season, and he was not participating in the sport during his treatment. This period of rest was crucial for healing.

Future follow-up X-rays are expected to show further healing and improved knee stability. This case demonstrates the importance of dynamic imaging in identifying both structural defects and instability, guiding an effective treatment plan for young athletes. Prolotherapy and PRP can be valuable tools in facilitating recovery and returning athletes safely to their sports. Whenever possible, treatment should ideally occur out of season to allow for optimal rest and healing.

The knee patient

Often, we will see a young patient in our examination room. The parents and the young patient will describe a knee problem that began when the knee became hyperextended during a game or gymnastics competition. The parents will tell us that they went to the “urgent care,” where they were told to use the RICE protocol of Rest, Ice, Compression, and Elevation.

After a few days of RICE, the parents told us that there was no improvement at all, and an appointment and consultation with a specialist led to an MRI and the discovery of the osteochondral lesion and diagnosis of Osteochondritis dissecans. For many we see, there was good news in that surgery would not be recommended. For others, we see that a more concerning recommendation for surgery will be given, especially in the presence of significant symptoms.

My daughter is 15

Knees: My daughter is 15, and she has osteochondritis dissecans in both knees. She also has knee instability from ligaments that need to be tightened. The specialist we are seeing wants to do surgery. She has also been diagnosed with Ehlers-Danlos Syndrome, and the surgeon feels that this is causing her pain from the knee popping out of place. My daughter does not want the surgery, so I am exploring options for her.

I have a 12-year-old son

Knees: I have a 12-year-old son. It is his left knee that has been the problem. He was diagnosed with osteochondritis dissecans, and it was recommended going to complete 6 months of conservative treatment that included physical therapy, muscle strengthening, and exercise. After 6 months, his pain was gone, which was a blessing; however, he still has issues with function. He can walk okay, but he has problems with steps, stairs, hills, and inclines. We have been to a few specialists, and they each have a different opinion. Some say operate, some say don’t operate, some say wait and see. We are looking for answers, but we only seem to get confused. 

My son is a pitcher, or he was a pitcher

Often, we will see the young gymnast or the youth league baseball pitcher with significant elbow problems. For the gymnast, the elbow problems present a significant challenge to various routines, including the floor exercises. We will often hear parents tell us about their “one-armed” gymnast. For the baseball pitcher, elbow problems mean a shutdown from playing.

Elbow: My son is a pitcher, or he was a pitcher. About a year ago, when he was 14, he was diagnosed with osteochondritis dissecans in his pitching elbow. We were also told at that time about a fracture in his growth plate. He was immediately told to rest and immobilize his arm. This included no throwing for three months. The physical therapy was very successful, enough so that he could return to playing; he just can’t pitch because his elbow is locking up. The doctors think this is from floating pieces of cartilage in his elbow. We have to consider the surgery. 

The theory as to why your child has Osteochondritis dissecans

Osteochondritis dissecans is a condition of cartilage and subchondral (under the cartilage) bone damage. Young athletes are typically affected in the knee, elbow, ankle, and hip. Repetitive microtrauma from sports is a common cause, especially among older adolescents and teenagers.

Here is learning point information (March 2019) from the National Center for Biotechnology Information and STATPearls publishing at the U.S. National Library of Medicine. (1)

• Osteochondritis dissecans (OCD) or “osteochondral lesion” is not a fully understood process. It is “idiopathic,” which means that doctors are not sure how it starts and develops, but they believe there are many factors that lead to this problem. Below, we will discuss joint instability as one of these causes.
• Osteochondral lesions range in severity from being asymptomatic (no pain or symptoms) to mild pain or advanced cases having symptoms of joint instability and locking. As the condition develops, cartilage fragments can break away and become “loose bodies” in the joint, causing pain and inflammation. When the patient has a loose fragment, symptoms are generally more severe, with marked joint pain, locking, swelling, and joint instability.

The theory as to why your child has Osteochondritis dissecans

• Doctors think that spontaneous osteonecrosis (joint deterioration caused by reduced blood flow)  is thought to occur during the transition from juvenile bone and cartilage development to mature bone and cartilage development in adolescence. The higher prevalence of Osteochondritis dissecans in young athletes suggests a repetitive microtrauma etiology.

Not growing pains

One of the problems that we see in our office is that the young athlete has not had medical treatment because of the thinking that the athlete’s problems, especially in the knee or elbow, are all part of “growing pains.” As pointed out in the research we are citing and confirmed by other research studies, these young patients typically show up in the specialists’ office several months to a year after the onset of symptoms.

“The management of osteochondritis dissecans continues to baffle even the savviest of surgeons”

In March 2020, Dr. Eric Edmonds of the University of California at San Diego wrote an editorial in the medical journal Arthroscopy (2). Here he notes:

“The management of osteochondritis dissecans continues to baffle even the savviest of surgeons, with unclear etiology, the unknown relationship of presentation to the outcome, bewildering response to various treatments, and frustratingly difficult-to-predict prognosis. Whether skeletal immaturity may be indicative of surgical success, at least when it comes to lesions requiring screw fixation, remains debatable. Treatment may include activity modification, drilling, fixation, or osteochondral replacement of osteochondritis dissecans lesions in the knee. Regardless, each osteochondritis dissecans lesion must be followed until osseous integration is confirmed by imaging -otherwise, progression of the disease to osteoarthritis is likely.”

Notice the words Dr. Edmonds uses: baffle, unclear, unknown, bewildering, and frustratingly difficult.

In the same March 2020 issue of Arthroscopy (3), surgeons from Icahn School of Medicine at Mount Sinai, New York, Wake Forest School of Medicine, Rush University Medical Center, and the University of Wisconsin published these findings on why patients failed surgery. They looked at two groups of patients: 26 skeletally mature patients (average age a little less than 18, 1-2) and 19 patients with incompletely closed physes (simply an open growth plate – average age just about 15 years old). These patients had screw fixation of osteochondral fragments, and 35 of these patients were followed up a minimum of two years after surgery.

The researchers noted:

• “No statistically significant difference in failure rates was found between skeletally mature and immature individuals.”
• The only factor significantly associated with fixation failure was undergoing a prior surgical procedure to address the osteochondritis dissecans lesion.”
• Analysis showed rates of overall survivorship from revision reoperations of 88.6% at 1 year and 68.8% at 5 years.

The researcher’s conclusion: The more surgeries, the worse.

“Outcomes after internal fixation of osteochondral fragments are guarded, with a fragment survival rate of 65.7% at a mean of 4.1 years’ follow-up. No difference in fragment survival was noted in skeletally mature versus immature patients. The only independent risk factor identified for fixation failure was the number of previous operations.”

In a July 2019 study in the medical journal Cartilage, (4) research led by doctors at the Rizzoli Orthopaedic Institute, in Bologna, Italy, examined the evidence of certain nonsurgical treatment strategies for knee Osteochondritis dissecans. The researchers looked at 27 studies that totaled an examination of 908 knees.

The treatments discussed were:

• (1) restriction of physical activity,
• (2) physiokinesitherapy (movement therapy) and muscle-strengthening exercises,
• (3) physical instrumental therapies, (examples are magnetic stimulation, infrared pulsed laser therapy et al.)
• (4) limitation of weight-bearing, and
• (5) immobilization.

The analysis showed an overall healing rate of 61.4%, with large variability (10.4% in one study to – 95.8% in another).

• A conservative treatment based on restriction of sport and strenuous activities seems a favorable approach, possibly combined with physiokinesitherapy.
• Negative prognostic factors were also identified:
  • larger lesion size,
  • more severe lesion stages,
  • older age and skeletal maturity,
  • the discoid meniscus, and
  • clinical presentation with swelling or locking.

The researchers here concluded:

“The literature on conservative treatments for knee Osteochondritis dissecans is scarce. Among different non-surgical treatment options, strenuous activity restriction seems a favorable approach, whereas there is no evidence that physical instrumental therapy, immobilization, or weight-bearing limitation could be beneficial. However, further studies are needed to improve treatment potential and indications for the conservative management of knee Osteochondritis dissecans.”

Pegs, Plugs, and Drills – Is there a surgical role for Osteochondritis Dissecans of the knee?

The papers noted above reflect a long line of research. In November 2017, in the publication Orthopaedics and Traumatology, Surgery and Research, (5) doctors in France gave a summary explanation of the standard treatment offered to patients with knee osteochondritis dissecans and the outcomes that may be expected.

• When the radiographic diagnosis of osteochondritis dissecans is made early in a patient, healing can often be obtained simply by restricting sports activities.
• The degree of lesion instability (bone or cartilage tears and cracks) can later be assessed by magnetic resonance imaging to see if healing with restricted sports occurred.
• When the lesion remains unstable (bone and/or articular cartilage tear has not healed and is loose or may tear away) and the pain persists despite a period of rest, surgery is indicated.
• Arthroscopic exploration is always the first step.
• Drilling of the lesion produces excellent outcomes if the lesion is stable. In this procedure, if the tear flap/bone is fixed and not a threat to breaking away and floating in the joint, drilling into the bone will bring blood to the cartilage tear and instigate healing. Please see our article Knee articular cartilage surgery and non-surgical repair for a more detailed discussion of various surgical procedures and drilling.
• Unstable lesions require fixation and, in some cases, bone grafting. (The osteocartilaginous block spoken about above has broken away, leaving a hole in cartilage or bone or both).

Arthroscopic Drilling for Stable Juvenile Osteochondritis Dissecans

A February 2022 paper in the journal Arthroscopy, Sports Medicine, and Rehabilitation (13) assessed the postoperative timeline for the return to activities of daily living in pediatric patients after arthroscopic drilling of a stable osteochondritis dissecans (OCD) lesion of the knee and to determine the rate of and risk factors for complications after the procedure.

• A total of 139 knees in 131 patients were evaluated, with an average age of 12.7 years, of which 102 (73%) were male knees.
• ” . . . findings suggest that arthroscopic drilling for stable, intact OCD lesions in the pediatric knee is a safe procedure with reliable outcomes and return to activities of daily living and minimal risk of complications. Most patients return to their preoperative daily activity level with a full range of motion of the knee 3 months after surgery. Complications, including reoperations, are related to the progression of the OCD lesion rather than to the surgical procedure. Each 1-cm2 increase in lesion size increases the likelihood of reoperation by 2.93 times. “

The cartilage plug and the bone peg

In the journal International Orthopaedics, (6) surgeons at the University Hospital of Montpellier suggest cartilage plugs for osteochondritis dissecans of the patella on a short-term basis. The plugs are inserted during an autologous osteochondral mosaicplasty. Cartilage is removed from a non-weight-bearing part of the knee and used to replace cartilage defects in the patella. The technique has been found reliable in the short term to restore the patellar joint surface and obtain satisfactory functional results.

Doctors in Japan (7) found that bone peg grafting, the removal of bone from a non-weight-bearing bone, and drilling it into an osteochondral bone defect could get adolescent baseball players back on the field in 12 months.

Understanding osteochondritis dissecans treatments in the elbow

In a May 2019 study in the medical journal Cartilage (8), researchers in Germany offered these observations of the problems of treating osteochondritis dissecans in the elbow:

• What causes osteochondritis dissecans in the elbow or open growth plates “remains as unclear as for the knee.”
• Mechanical factors (throwing activities) seem to play an important role.
• Clinical symptoms are nonspecific. Imaging techniques are then important for the diagnosis. In low-grade and stable lesions, treatment involves rest and different degrees of immobilization until healing.
• When surgery is necessary, the procedure depends on the OCD stage and on the state of the cartilage.

High-demand upper extremity activities, such as baseball or gymnastics

In February 2020, in the journal Current Reviews in Musculoskeletal Medicine, (9) researchers wrote of the problem of osteochondritis dissecans in the elbow and the surgical fix and possible failure.

“Patients at high risk for the development of this condition are involved in high-demand upper extremity activity such as baseball or gymnastics. Treatment options include non-operative management, drilling, fixation, loose body removal/microfracture, osteochondral autograft, and osteochondral allograft. Cartilage preservation procedures (i.e., osteochondral autograft) have a significant advantage in terms of clinical and radiographic healing compared with fixation or microfracture. Capitellar OCD lesions (the cartilage covering the outside part of the humerus bone at the elbow) afflict a large number of adolescent athletes today and will likely continue to increase in number from sports-related injuries.

It is critical to recognize and treat these lesions in a timely and appropriate fashion to optimize clinical outcomes. When faced with the failure of healing, surgeons must critically analyze reasons for failure, including post-operative compliance, return to high-demand sporting activity, fixation of non-viable fragments, utilization of microfracture, alignment, and concomitant pathology.”

Prolotherapy injections for Osteochondritis dissecans

We have been treating Osteochondritis dissecans for over three decades. We published two case studies in the Journal of Prolotherapy (10) concerning young baseball players seen at Caring Medical.

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, and reliable alternative to surgical and ineffective conservative care treatments.

Summary transcript:

When a child or young athlete develops osteochondritis dissecans (OCD), the focus is often placed on the damaged cartilage or bone seen on MRI. But an important question remains: Why did that injury develop in the first place?

To understand OCD, it helps to think about what happens when excessive pressure is placed on soft tissue. If constant pressure is applied to any part of the body without allowing normal blood flow to return, the tissue begins to break down. Over time, this damage can extend deeper until even the underlying bone is affected.

A similar process can occur inside a joint.

In osteochondritis dissecans, repetitive loading creates inflammation where the cartilage meets the underlying bone. As this stress continues, blood flow to a portion of the bone may become compromised. Without an adequate blood supply, the bone weakens, and eventually, a fragment of bone and cartilage can partially or completely separate from the surrounding joint surface.

OCD is commonly described as an overuse injury, particularly in young athletes who participate in running and jumping sports. But that explanation alone does not answer an important question: Why does one athlete develop OCD while another with the same training volume never does?

One possible explanation is joint instability.

Ligaments are responsible for holding bones together and maintaining normal joint mechanics. When ligaments become stretched or injured, they may no longer adequately stabilize the joint. Even subtle instability can alter how forces are distributed across the cartilage and underlying bone.

Imagine two children who both run track. They train the same amount and compete at the same level. One develops OCD while the other remains healthy. If one child’s ligaments allow excessive joint motion, repetitive athletic activity may concentrate abnormal forces onto a small portion of the joint. Instead of forces being evenly distributed, they become focused on one area, creating chronic overload. Over time, this may contribute to inflammation, impaired blood flow, and eventually an OCD lesion.

OCD most commonly affects the knee but can also occur in the ankle, elbow, hip, and other joints. Early symptoms often include pain, swelling, or a clicking and catching sensation. As the condition progresses, the damaged bone and cartilage may begin to loosen. Eventually, a fragment can detach completely and become a loose body within the joint.

MRI studies often show these lesions as a defect in the bone beneath the cartilage, sometimes appearing as though a small piece has been removed from the joint surface. Physicians classify OCD according to stages, ranging from early stable lesions to complete detachment.

Early diagnosis is important because treatment recommendations often depend on the stage of the lesion. In skeletally immature patients, stable lesions may heal with activity modification and protected weight bearing. However, not every child responds to rest alone. If the underlying cause—such as persistent joint instability—remains unaddressed, symptoms may return when sports activities resume.

The same biomechanical principles may also contribute to other conditions involving loss of blood supply to bone, including osteonecrosis in areas such as the ankle. When abnormal forces continue across an unstable joint, surrounding cartilage and bone may experience repetitive overload, increasing the risk of degeneration.

At our practice, we begin by identifying why abnormal loading developed. This includes a detailed physical examination, stress imaging when appropriate, motion X-rays, ultrasound evaluation of supporting ligaments, and MRI review to determine the severity of the lesion.

When ligament laxity is identified, our goal is to improve joint stability. Depending on the patient’s condition, treatment options may include dextrose prolotherapy, platelet-rich plasma (PRP), or bone marrow concentrate-based regenerative procedures. Treatment plans are individualized according to the patient’s age, severity of injury, activity goals, and overall health.

Equally important is working alongside physical therapists, athletic trainers, coaches, and other healthcare providers to develop a rehabilitation program that restores strength, movement, and a safe return to sport.

Rather than focusing solely on the damaged cartilage, we believe it is equally important to understand why the damage occurred. Addressing joint instability may help restore more normal joint mechanics, reduce abnormal stresses, and support the body’s healing process while helping athletes safely return to the activities they enjoy.

Osteochondritis Dissecans of the Knee in a 13-Year-Old Athlete

A 13-year-old athlete, J.C., came to Caring Medical seeking another opinion after being diagnosed with bilateral osteochondritis dissecans (OCD) of the knees. He was an exceptionally active young athlete who played competitive baseball and soccer, and also enjoyed rollerblading, swimming, and bicycling.

His orthopedic surgeon recommended that he stop all athletic activities to determine whether the lesions would heal on their own. The family was advised that if his symptoms did not improve with rest, surgery would likely be the next step.

By the time of his evaluation at Caring Medical, J.C. had significantly reduced his athletic participation and was relying on ice and ibuprofen to manage his pain. Despite these measures, he continued to experience diffuse pain throughout both knees that became much worse with physical activity, particularly running.

During the physical examination, multiple areas of tenderness were found around both knees, along with generalized ligament laxity, suggesting underlying joint instability. X-rays confirmed the diagnosis of osteochondritis dissecans in both knees.

The diagnosis, the potential role of ligament laxity, and the principles of Prolotherapy were discussed in detail with J.C. and his parents. After reviewing the available treatment options, the family elected to postpone Prolotherapy at that time while continuing to monitor his condition.