Osteochondral defect

[JMill]

Thank you for providing this information publicly. I've learned a lot from Barbell Medicine over the years.

In someone with a history of osteochondral defect of the medial femoral condyle, is this a situation to "listen to the pain" and be extra conservative with exercise dosage because of the pain more than it would for someone with acute onset low back pain?

To put this question in context, I am currently dealing with a knee pain flare up and have a history of osteochondral defect. I have pain with weight bearing knee in 0-40ish degrees positions, so squats in a bottom position and going up a flight of stairs are totally pain-free, yet walking out a squat and initiating the movement is excruciating. Pain seems to be intensifying with the more activity I do and even walking more than 10 minutes seems to flare up the symptoms. With previous injuries to low back and muscle areas, the more I did, the better I felt. However, this issue seems to have the opposite relationship. I'm asking to see if maybe I've been nocebo'd by my physician's description of my osteochondral defect, which was initially found about ten years ago when he said I would definitely need a knee replacement when I got older. Also trying to figure out if I'm sensitizing/further injuring my knee by doing bottom position lunges and other somewhat tolerable exercises.

[Derek Miles]

Hey, thanks for reaching out. This is an instance where you are going to hear me rely much more on clinical experience than be able to do a deep dive with citations as we do not have a lot of great information on long term OCD management. My typical recommendations for being more conservative are much more related to swelling than anything else. It does not look like you have any real report here of that which tends to end with the *normal* recommendations regarding load and range of motion management.

Anytime more activity tends to flare symptoms, we probably need to make some modifications. The real question is always what constitutes "more." If it is the same set of exercises, performed in the same way, that can sometimes be problematic. Changing the exercise, or even how it is performed, can help to increase tolerance and let you work around a problem a bit. If an athlete is having symptoms in that 0-40 range, you would probably see me using an exercise like a modified pistol through the top range of motion, or a heel tap (standing on one leg on a step and going down slowly to tap the heel to the ground on the other) where I could slowly increase the range of motion through which I was exposing the joint.

Given where your report of symptoms occurs, I likely would also be working on some exercises like farmer's walks where we are mimicking the smaller flexion angles in a loaded manner. You are not further injuring your knee by training any exercise and really, the way to increase tolerance to positions is to slowly get into them more and in different ways. If I were you, I would try to get some of the *more* from different exercises, and different positions right now until symptoms start to subside, then things can pare back to what you were doing.

[JMill]

This description of general OCD management really helps, Derek. I've had a hard time finding published and non-published guidance on this.

I have had a bit of swelling/effusion. The test where you push on the pouches of the knee and assess how easily the knee joint fluid stays in the knee (I don't know the reliability of this test) indicated I usually have moderate swelling and this seems to be worse at the end of the day and sometimes worse after certain exercises.

I will keep your general information about OCD management in mind as I try to navigate self-management with the hope of returning to recreational basketball and tennis, along with a strength training routine. I may end up reaching out for an injury consultation as I work through this process.

Many thanks for taking the time to explain this!