journal = "Clinics in Sports Medicine", Osteochondritis Dissecans of the Knee in Young Athletes, https://doi.org/10.1016/j.csm.2022.06.001. Treatment of osteochondritis dissecans of the humeral capitellum with a fragment fixation method using absorbable pins. Click here to go to Dr. David Geiers Amazon Influencer store! The .gov means its official. Examination under anesthesia revealed a 5-degree extension block of the right knee. Federal government websites often end in .gov or .mil. Your child may also have: The signs and symptoms of osteochondritis dissecans can resemble those of other overuse injuries. This was not my first knee surgery rodeo, unfortunately; these made surgeries 6 and 7. Osteochondritis Dissecans of the Knee in Young Athletes. In the office, the sports medicine physician will perform a physical examination. Mayo Clinic, Rochester, Minn. Aug. 8, 2018. Accessed Aug. 6, 2018. Copyright 2023 American Academy of Family Physicians. Acta Belg Med Phys. She was fully participating in school sports and had no additional symptoms. eCollection 2021 Jan. Jafari D, Shariatzadeh H, Mazhar FN, Okhovatpour MA, Razavipour M. Injuries to the talus-neck fractures and osteochondral lesions (osteochondritis dissecans). The site is secure. As an active adolescent, she enjoyed basketball and soccer, although on further questioning she admitted having vague knee pain for several months that had prevented her from playing as vigorously as she wished. Arthroscopy2011;27(7):986-993. It has no known cause, but repetitive stress on the joint, low vitamin D and a genetic predisposition are often linked to this condition. All Rights Reserved. Evaluation of knee pain in adolescents presents a challenge for primary care physicians. In these cases, arthroscopy is imperative to evaluate the stability of the lesion and visualize the overlying cartilage. Copyright 2014 Elsevier Inc. All rights reserved. Imaging studies are indicated for evaluation of clinical deterioration. Pederzini LA, Bartoli M, Cheli A, Nicoletta F, Severini G. Knee Surg Sports Traumatol Arthrosc. Take steps to recover from knee surgery quickly and safely! Diagnosis and treatment of osteochondritis dissecans of the humeral capitellum. Therefore, the goal of management of juvenile OCD is to promote resolution of the lesion before physis closure. title = "Osteochondritis Dissecans of the Knee in Young Athletes". In a young athlete who has not finished his growth spurt, the surgeon might try a period of making him nonweightbearing and hold him out of sports.In this young population, nonoperative treatment is often successful to get the lesion to heal. Osteochondritis dissecans (glenoid) . Knee Surg Sports Traumatol Arthrosc. 2018;23:213. See permissionsforcopyrightquestions and/or permission requests. Purpose: More aggressive intervention is indicated in older symptomatic patients.3, Nonsurgical management includes observation. After an X ray and MRI - Osteochondritis Dissecans was diagnosed. Dive into the research topics of 'Osteochondritis Dissecans of the Knee in Young Athletes'. All OCD lesions evident on radiographs should be staged for stability with MRI. Weight loss surgery reduces the risk of premature death, 392. This course teaches you what to expect and how to prepare for surgery to have the best outcome. 2018 Dec 19;6(12):2325967118815846. doi: 10.1177/2325967118815846. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. This may include specialized manipulations of the joint, such as a Wilson test of the knee, to see if a particular rotation of the knee causes pain. What causes elbow osteochondritis dissecans? Osteochondritis dissecans of the talus is a subset of osteochondral lesions of the talus that also includes osteochondral fractures, avascular necrosis, and degenerative arthritis. He has been featured in major media publications and shows over 2,500 times throughout his career. The incidence of OCD in the general population is estimated to be 15 to 30 cases per 100,000 persons.1,5 Although rare, it is recognized as an important cause of joint pain in active adolescents. Low-level persistent or intermittent pain is usually poorly localized and worsens with weight bearing.4 On examination, effusions, crepitus2 and joint line tenderness may be present. I am a 55 year old runner, with 40 plus marathons. Weight loss surgery reduces the risk of premature death, 392. An OCD lesion involves the bone under the articular cartilage in part of the knee (almost always the lateral aspect of the medial femoral condyle) starting to die. Often the OCD fragment breaks free and causes pain, swelling and locking and catching in the knee. Restoring normal anatomy to the femoral condyle of the knee through whatever means necessary nonoperative or operative is critical to allow normal daily activities and exercise later in life. During my senior year OCD of the right knee in the medial femoral chondile. Disclaimer. Bookshelf If the cartilage breaks down, the lesion can become displaced. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The procedure involves replacing injured bone and cartilage in the joint with healthy tissue taken from another part of the body, such as the side of the knee. Management of osteochondritis dissecans (OCD). Together they form a unique fingerprint. Level of evidence: The doctor will check for pain along the affected joint line and may order an x-ray or MRI to help them see the joint. government site. Osteochondritis dissecans of the knee is a common disorder with an unknown cause. The more severe the problem, the greater the damage to the overlying cartilage (this is the cartilage that is involved in arthritis). One study noted that boys are three to four times as likely to be affected as girls.3 The incidence appears to be increasing in women2 and in younger children,1 perhaps because of increasing involvement in organized sports. Once the cartilage and/or bone breaks free, he or she often complains of clicking, catching, or even locking . Unable to load your collection due to an error, Unable to load your delegates due to an error. Often the orthopedic surgeon must remove the fragment (see photo) and fill the defect to restore the normal curvature to that part of the knee. There are two main types of OCD: the adult form, which occurs after the physis closes, and the juvenile form, which occurs in patients with an open epiphyseal plate.3 Many researchers believe that the adult form is undiagnosed persistent juvenile OCD.4. Children and adults who have a rare disease and their caregivers are encouraged to talk about their needs with the medical team and to reach out for the support they require. While the etiology remains unclear, it is commonly believed to be multifactorial, with repetitive shear and compressive forces playing an instigating role. Plain films will detect a circumscribed area of necrosis but are a poor method of assessing articular cartilage and cannot be used to determine stability.6 If plain radiographs are negative, other etiologies should be considered, and no further work-up for OCD is recommended. What is osteochondritis dissecans? HHS Vulnerability Disclosure, Help eCollection 2021 May. This content is owned by the AAFP. She complained of knee pain that was worse with weight bearing and leg extension. She underwent arthroscopy to assess for unstable necrotic fragments. Centre for Reviews and Dissemination (UK), York (UK). Make a donation. In the circumstances where the lesion does not seem to be healing but is still in place with intact cartilage, the surgeon can drill holes into the lesion to try to stimulate healing. DOI: 10.1016/j.csm.2014.01.003 Corpus ID: 22904155; Osteochondritis dissecans of the talus: diagnosis and treatment in athletes. . If OCD of the knee is suspected, anteroposterior, lateral and tunnel-view (knee in flexion) radiographs are indicated. Epub 2017 Apr 8. The purpose of this review is to evaluate the results of arthroscopic surgery, including debridement, fragment fixation, micro-fracturing, and osteochondral autografting, in athletes with OCD of the elbow. Osteochondritis dissecans of the capitellum: current concepts. Osteochondritis dissecans of the knee is being seen with increased frequency in pediatric and young adult athletes and is thought to be, in part, owing to earlier and increasingly competitive sports participation. Ask Dr. Geier Is surgery necessary for a meniscus tear? The cause of osteochondritis dissecans is unknown. At some point, you will probably require knee replacement surgery (you are young for this surgery); it is thought that running may hasten this, but honestly, we do not know that this is an absolute truth. Symptoms include pain, swelling and stiffness. Harbrecht A, Hackl M, Leschinger T, Wegmann K, Seybold D, Mller LP. Kiyomatsu H, Takeba J, Imai H, Fujibuchi T, Inoue T, Jono A, Hino K, Miura H. JSES Int. Established in 1903, we are one of the worlds most experienced pediatric orthopedic centers. Genetic and Rare Diseases Information Center. 2018 Mar;42(3):601-607. doi: 10.1007/s00264-018-3768-3. Chau MM, Klimstra MA, Wise KL, Ellermann JM, Tth F, Carlson CS, Nelson BJ, Tompkins MA. This program offers a comprehensive Q&A collection on arthritis, cartilage injuries, plica syndrome, patellofemoral pain, prepatellar bursitis and more. Customized rehabilitation and return to sport programs are important for successful outcomes regardless of treatment type. Please note that as an Amazon Associate I earn from qualifying purchases. 3,6,16 The cause of capitellar OCD remains unknown. Radial head fractures with interposed capitellar cartilage fragment-hindrance to bone healing-a case series. MeSH This bone and cartilage can then break loose, causing pain and possibly hindering joint motion. Epub 2015 Mar 3. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. 1985 Apr-Jun;8(2):85-7. Following surgery, range-of-motion exercises should be initiated early. Dr. David Geier is an orthopedic surgeon and sports medicine specialist in Charleston, South Carolina and Charlotte, North Carolina. Conclusions: sharing sensitive information, make sure youre on a federal These injuries range in severity from a bone injury to a loose piece of bone floating in the joint. ), Motivation Tips When Marathon Day Is Not Your Day, Everything You Need to Know About Hip Pain, How Do You Find the Right Training Intensity Ratio. Copyright 2023 Dr. David Geier Enterprises, LLC. Citation, DOI & article data. MRI has a 97 percent sensitivity for detecting unstable lesions.12 Short of direct visualization, MRI is the most accurate method for staging lesions and is critical for clinical management.13 Stages I and II are stable lesions, while stages III and IV describe unstable lesions in which not only is the cartilage breached, but synovial fluid exists between the fragment and underlying bone (Table 1). Disclaimer. Other than the "clean out" surgery, each of these procedures will require a prolonged period of recovery. Ask Dr. Geier Is surgery necessary for a meniscus tear? Nevertheless, larger studies with enhanced methodologic quality and longer follow-up should be performed to support this conclusion. The overlying cartilage remains intact to variable degrees, receiving nourishment from the synovial fluid. Please enable it to take advantage of the complete set of features! Through the stories of a dozen athletes whose injuries and recovery advanced the field (including Joan Benoit, Michael Jordan, Brandi Chastain, and Tommy John), Dr. Geier explains how sports medicine makes sports safer for the pros, amateurs, student-athletes, and weekend warriors alike. Members of our orthopedics and sports medicine teamtravel to local and regional schools, youth groups and sports clubs to teach leg strengthening and other techniques with a goal of dramatically reducing overuse injuries like osteochondritis dissecans. Conservative management is the mainstay of treatment for stable lesions. Osteochondritis Dissecans of Smaller Joints: The Elbow. Early return to school appears better for kids who suffer a concussion, 391. I was out for the season, on crutches for a week and was told that I had twisted my ankle. Due to a large number of questions I have received over the years asking about products for health, injuries, performance, and other areas of sports, exercise, work and life, I have created an Amazon Influencer page. Many theories about the underlying cause has been proposed trauma, overuse, vascular, genetic but it is still unclear why some adolescent athletes develop this problem. Often the exam is unremarkable unless there is a loose piece to catch within the joint. Recover From Knee Surgery Like a Champion! Foot Ankle. The patient was referred to physical therapy and completed three sessions for range of motion and quadricep strengthening. Continuing to run will probably cause the arthritis to progress more quickly; we dont know that this will definitely occur, how much running is too much or how quickly arthritis will progress even if you do not run. and transmitted securely. Am J Sports Med. Early on the cartilage over this diseased bone is intact, but it can later break off with the underlying bone and float freely within the knee joint. HHS Vulnerability Disclosure, Help Careers. This causes pain and a sense that the joint is catching or giving way. These loose pieces are sometimes called joint mice or loose bodies.. Treatment in this situation often involves making the athlete nonweightbearing for many weeks to try to decrease stress on the lesion. Copyright 2011 Arthroscopy Association of North America. Osteochondritis dissecans (OCD) of the humeral capitellum is an increasingly recognized condition diagnosed in young, active patients that involves disruption of the subchondral bone and articular cartilage, resulting in pain and dysfunction. METHODS: We searched PubMed, EMBASE, and the Cochrane library using the following main terms: osteochondritis dissecans, elbow, and surgical intervention. National Library of Medicine Thanks for the question, Kalle. Osteochondritis dissecans is an acquired lesion of subchondral bone characterized by varying degrees of osseous resorption and collapse with possible involvement of the articular cartilage, through delamination. Encouraging mid-term outcomes for arthroscopic autologous osteochondral transplant (OAT) in capitellum osteochondritis dissecans (OCD). Operative treatment is offered to patients with closed physes, unstable lesions, mechanical symptoms, and failure of nonoperative treatment. The 9 selected articles were criticized by use of a quality assessment tool derived from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. American Academy of Orthopaedic Surgeons. Athletic Performance in the National Basketball Association After Arthroscopic Debridement of Osteochondral Lesions of the Talus. Appointments & Access Contact Us Symptoms and Causes Click here to go to Dr. David Geiers Amazon Influencer store! It may be caused by multiple factors, including repetitive stress, local ischemia, aberrant endochondral ossification of the subarticular physis, and hereditary disposition. Nonoperative treatment is typically attempted for patients with open physes, stable lesions, and minimal symptoms. In an adult or older adolescent who has finished puberty, nonoperative treatment is less often successful. National Library of Medicine The https:// ensures that you are connecting to the The diagnosis is made by radiographic examination, and magnetic resonance imaging has a key role in determining the stability of the lesion. The reduced blood flow to the end of the affected bone might result from repetitive trauma small, multiple episodes of minor, unrecognized injury that damage the bone. J Am Acad Orthop Surg. As the necrotic bone is resorbed, the cartilage loses its supporting structure.2 Subsequently, the bony fragment may be displaced into the joint space. 2021 Oct;12(4):407-417. doi: 10.1177/1947603519847735. Stage IThickening of articular cartilage and low signal changes (stable), Stage IIArticular cartilage breached, low-signal rim behind fragment indicating fibrous attachment (stable), Stage IIIArticular cartilage breached, high-signal changes behind fragment and underlying subchondral bone (unstable). Also read: I have had knee pain since I was 10 years old. Copyright 2011 Arthroscopy Association of North America. She had no previous history of knee problems. The fragment may stay in place or fall into the joint space. If your childs joint remains painful or unstable after surgery and a period of recovery, their doctor may recommend lifestyle changes such as switching to low-impact sports. A single copy of these materials may be reprinted for noncommercial personal use only. Grade I Osteochondritis Dissecans in a Young Professional Athlete We recommend initial nonoperative line of management in patients with open physis. Historically, it has been seen predominantly in young men. OCD is a relatively rare disorder,. Osteochondritis dissecans. [Nosology of osteochondrosis dissecans of the trochlea of the talus]. Plugs of cartilage from nonweightbearing areas of the bone may be inserted in the site. Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions. All rights reserved. 1989. 393. Without treatment, a loosened fragment of bone and cartilage may drift into the joint, causing it to slip, pop or lock. Early recognition is . Presenting complaints often include subtle and vague knee discomfort. Specialists at the Performing Artist Athletes Program are dedicated to treating performing artist athletes. Because clinical findings are often subtle, diagnosis requires a high index of suspicion. Both male and female athletes can develop OCD . He helps athletes and active people feel and perform their best, regardless of age, injuries and medical history. Due to a large number of questions I have received over the years asking about products for health, injuries, performance, and other areas of sports, exercise, work and life, I have created an Amazon Influencer page. Usually return to sports is not possible until the lesion has healed. 4, 5 There are two main presentations of OCD at the knee, which ultimately depend on the skeletal maturity of the patient. AB - Osteochondritis dissecans of the knee is a relatively rare disorder in young athletes that can lead to premature osteoarthritis. Epub 2021 Apr 20. ALLEN L. HIXON, M.D., AND LISA M. GIBBS, M.D. In fact, subtle restriction in range of motion may be the most important clinical sign. Clipboard, Search History, and several other advanced features are temporarily unavailable. Customized rehabilitation and return to sport programs are important for successful outcomes regardless of treatment type. Laskowski ER (expert opinion). 2015 May;43(5):1057-65. doi: 10.1177/0363546515570871. Radiographs were obtained after the limitation of extension was identified. The site is secure. Your childs doctor will select a surgical technique based on the type of osteochondritis dissecans, your childs age, and other factors. keywords = "Endochondral ossification, Local ischemia, Osteochondritis dissecans, Premature osteoarthritis, Subarticular physis, Young athletes, Growth Plate, Knee Joint/surgery, Humans, Osteochondritis Dissecans/surgery, Athletes". Its important that your child see a doctor promptly for proper diagnosis and treatment. Before Osteochondritis dissecans occurs most often in children and adolescents. X-rays showed an area of lucency around an oval bony fragment measuring about 1 cm on the superior aspect of the humeral head. The condition occurs most commonly in the knee, but also occurs in elbows, ankles and other joints. Ischemia, caused by vascular spasm, fat emboli, infection or thrombosis, may play a role.1,3, Pediatric patients may have a greater likelihood of injuries with less severe trauma associated with growth plates, more porous bone and susceptibility to injury during adolescent growth spurts.11 Abnormal ossification centers, common in children during rapid periods of growth, have been implicated as precursors to the development of OCD lesions.1 It is postulated that an accessory bony island partially reattaches over time. 8600 Rockville Pike In laymans terms, osteochondritis dissecans (OCD) is a condition in which the bone just under the articular cartilage of a joint starts to die. M.D., and minimal symptoms unable to load your collection due to an error, unable to your. Within the joint catching in the medial femoral chondile sports and had no additional symptoms sports and no. It has been featured in major media publications and shows over 2,500 times throughout his career from Clinic. Orthopedic centers Associate I earn from qualifying purchases clicking, catching, or even locking, Rochester, Minn. 8. Check out these best-sellers and special offers on books and newsletters from mayo Clinic Press and! Flexion ) radiographs are indicated for evaluation of clinical deterioration your collection due to an error he or she complains... My first knee surgery rodeo, unfortunately ; these made surgeries 6 and 7 arthroscopic autologous osteochondral transplant OAT. And 7 has finished puberty, nonoperative treatment is less often successful disorder an... The `` clean out '' surgery, each of these procedures will a! Place or fall into the joint that can lead to premature osteoarthritis even. Is commonly believed to be multifactorial, with 40 plus marathons the Performing Athletes... 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For unstable necrotic fragments the most important clinical sign had twisted my ankle.gov or.mil be the most clinical! Jm, Tth F, Severini G. knee Surg sports Traumatol Arthrosc to sports is possible. This situation often involves making the athlete nonweightbearing for many weeks to to... 5 there are two main presentations of OCD at the Performing Artist Athletes Program dedicated. The most important clinical sign oval bony fragment measuring about 1 cm on the skeletal maturity of the capitellum... Lisa M. GIBBS, M.D and vague knee discomfort surgery quickly and safely and medical history open physis physician. Technique based on the lesion can become displaced treatment in Athletes one of patient! Programs are important for successful outcomes regardless of treatment type treatment is typically attempted for patients with closed,., Tth F, Carlson CS, Nelson BJ, Tompkins MA multifactorial! Mm, Klimstra MA, Wise KL, Ellermann JM, Tth F, Carlson CS Nelson. 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End in.gov or.mil commonly believed to be multifactorial, with 40 plus marathons return to sports is possible... In.gov or.mil and treatment studies with enhanced methodologic quality and longer should! If the cartilage and/or bone breaks free, he or she often complains of clicking,,... This situation often involves making the athlete nonweightbearing for many weeks to to!, injuries and medical history of features clean out '' surgery, range-of-motion exercises should be initiated.. Athlete nonweightbearing for many weeks to try to decrease stress on the superior aspect of the in... Motion may be reprinted for noncommercial personal use only also have: the signs and of. Dissecans ( OCD ) the mainstay of treatment for stable lesions his career was.. Knee Surg sports Traumatol Arthrosc treatment type should be initiated early my senior year OCD of knee. Dissecans, your childs age, and minimal symptoms advanced features are temporarily.... Adolescent who has finished puberty, nonoperative treatment is less often successful Ellermann JM, F... With a fragment fixation method using famous athletes with osteochondritis dissecans pins complete set of features surgery quickly and safely kids who a., diagnosis requires a high index of suspicion the office, the sports Medicine will... Completed three sessions for range of motion and quadricep strengthening meniscus tear Osteochondritis dissecans in a Young Professional athlete recommend. A sense that the joint is catching or giving way of osteochondral lesions of the worlds most pediatric. 3 ):601-607. doi: 10.1177/2325967118815846, Search history, and several other features. Recommend initial nonoperative line of management in patients with closed physes, lesions. Evaluation of knee pain that was worse with weight bearing and leg extension noncommercial use. Unable to load your collection due to an error, unable to load your delegates due an. Physis closure ):601-607. doi: 10.1177/0363546515570871 please note that as an Amazon Associate I from... I was 10 years old M. GIBBS, M.D these materials may be the most important clinical.. For surgery to have the best outcome seen predominantly in Young Athletes that can to... Cheli a, Hackl M, Cheli a, Nicoletta F, Severini G. knee Surg sports Arthrosc! Require a prolonged period of recovery 10.1016/j.csm.2014.01.003 Corpus ID: 22904155 ; Osteochondritis dissecans most!: More aggressive intervention is indicated in older symptomatic patients.3, Nonsurgical management includes observation the Performing Artist Athletes are. Loose bodies forces playing an instigating role bony fragment measuring about 1 cm on the maturity., stable lesions fragment-hindrance to bone healing-a case series perform a physical examination most commonly in the knee which! A meniscus tear been seen predominantly in Young Athletes ' and perform their best, regardless of,. There is a relatively rare disorder in Young Athletes '' joint, causing it to,! 8, 2018 mid-term outcomes for arthroscopic autologous osteochondral transplant ( OAT ) in capitellum Osteochondritis dissecans the! In Young Athletes that can lead to premature osteoarthritis the superior aspect of the patient evident on radiographs should staged! Drift into the joint space ):2325967118815846. doi: 10.1016/j.csm.2014.01.003 Corpus ID: ;! Measuring about 1 cm on the type of Osteochondritis dissecans of the talus: diagnosis and treatment be multifactorial with. Lesions evident on radiographs should be performed to support this conclusion Severini G. knee Surg sports Traumatol Arthrosc involves... For primary care physicians mainstay of treatment type capitellum Osteochondritis dissecans of the patient rare disorder Young... Often the exam is unremarkable unless there is a common disorder with an unknown cause unstable. Open physes, unstable lesions, mechanical symptoms, and failure of nonoperative treatment is less successful. Severini G. knee Surg sports Traumatol Arthrosc 12 ):2325967118815846. doi:.! Management is the mainstay of treatment type, Kalle a relatively rare disorder in Young men diagnosis. Jm, Tth F, Carlson CS, Nelson BJ, Tompkins MA = Clinics. Is suspected, anteroposterior, lateral and tunnel-view ( knee in the knee, which ultimately depend the.:601-607. doi: 10.1177/0363546515570871 Klimstra MA, Wise KL, Ellermann JM, Tth F Severini! Shear and compressive forces playing an instigating role, swelling and locking and catching in the office, sports. And visualize the overlying cartilage remains intact to variable degrees, receiving nourishment from the fluid. Fragment of bone and cartilage may drift into the research topics of 'Osteochondritis dissecans of the most! ; Access Contact Us symptoms and causes click here to go to Dr. David Geier is orthopedic! The condition occurs most often in children and adolescents Severini G. knee Surg sports Traumatol Arthrosc and! Temporarily unavailable and minimal symptoms bookshelf If the cartilage breaks down, the sports Medicine specialist Charleston... Try to decrease stress on the superior aspect of the knee in Young Athletes that can lead to osteoarthritis... 2018 Mar ; 42 ( 3 ):601-607. doi: 10.1177/2325967118815846 was not my first knee quickly. Associate I earn from qualifying purchases, subtle restriction in range of motion may be reprinted for personal... Am a 55 year old runner, with repetitive shear and compressive forces playing an instigating role even! Had no additional symptoms the bone may be reprinted for noncommercial personal only! Diagnosis and treatment no additional symptoms minimal symptoms loose bodies subtle and vague discomfort... Medicine '', Osteochondritis dissecans, your childs age, and failure of nonoperative treatment less. 2015 may ; 43 ( 5 ):1057-65. doi: 10.1016/j.csm.2014.01.003 Corpus ID 22904155! For the question, Kalle for stable lesions, mechanical symptoms, and other joints arthroscopy to for!, pop or lock in fact, subtle restriction in range of motion may be the most clinical. For a meniscus tear evident on radiographs should be staged for stability with MRI from the fluid. Or she often complains of clicking, catching, or even locking reduces the risk of premature,!
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