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Osteochondritis Dissecans of the Capitellum (OCD)

Necrosis and fragmentation of the cartilage and subchondral bone of the humeral capitellum, affecting young athletes aged 12-16 (gymnasts, throwers, tennis players). Due to repetitive compression overload of the lateral compartment. ICRS/Nelson classification with 4 stages.

Characteristics

Osteochondritis dissecans of the capitellum (OCD) is a localized osteochondral lesion of the humeral capitellum, resulting from focal avascular necrosis of the articular cartilage and underlying subchondral bone [1]. It mainly affects young adolescent athletes aged 12-16, with male predominance (3:1), practicing throwing sports (baseball, javelin), gymnastics (weight-bearing on hands) or tennis. Incidence is estimated at 3.4 per 10,000 in adolescent athletes.

The pathophysiology is based on mechanical compression overload of the lateral elbow compartment: axial forces compress the radial head against the capitellum, causing microvascular injuries to the subchondral bone (vulnerable terminal vascularization in the growing child) [2]. It is essential to differentiate OCD from Panner's disease, occurring in younger children (< 10 years), which is self-limiting with good spontaneous prognosis.

Diagnosis relies on MRI which specifies the size, location and stability of the osteochondral fragment. The ICRS/Nelson classification distinguishes 4 stages. Conservative treatment is indicated for stages I-II in children with open growth plates. Stages III-IV require arthroscopic treatment (fragment fixation, microfractures, mosaicplasty) [3].

  • The capitellum is the convex articular surface of the lateral humeral palette, articulating with the radial head. Its vascularization is terminal (posterior epiphyseal arteries) and particularly vulnerable in the growing child. OCD typically affects the anterolateral face of the capitellum, the zone of maximum compression during weight-bearing and throwing.
  • The mechanism is repetitive lateral compression overload: the radial head compresses the capitellum during the weight-bearing phase (gymnastics) or the acceleration phase of throwing (baseball, javelin). Repeated microvascular injuries cause focal avascular necrosis of the subchondral bone, followed by progressive fragmentation of the overlying cartilage.
  • Risk factors: intensive sport before skeletal maturation (12-16 years), gymnastics with repetitive weight-bearing, baseball (pitchers), competitive tennis, excessive training volume, early sport specialization, genetic predisposition (bilateral OCD in 20-30% of cases), open growth plates.
  • Complications: loose body from osteochondral fragment detachment, early humeroradial compartment arthritis, residual range-of-motion loss, recurrent joint locking, mirror lesion of the radial head from chronic impingement, capitellum growth insufficiency in children.

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  1. Stage I – Stable fragment in situ

    Articular cartilage softening with subchondral bone lesion without fissure or displacement. MRI showing abnormal subchondral bone signal of the capitellum (medullary edema) with intact surface cartilage. Stable fragment in place. Conservative treatment with sports rest. Excellent prognosis in children with open growth plates.

  2. Stage II – Partially detached fragment

    Partially detached osteochondral fragment with visible surface cartilage fissure. MRI showing a partial separation line between the fragment and healthy bone with incomplete fluid rim. Fragment still attached by a cartilaginous or bony bridge. Conservative treatment possible if fragment predominantly stable, otherwise arthroscopic fixation.

  3. Stage III – Complete non-displaced fragment

    Completely detached osteochondral fragment remaining in its niche (non-displaced). MRI showing a complete fluid rim around the fragment. Niche visible at arthroscopy. Fragment potentially fixable if good quality and sufficient size. Surgical treatment: fixation if possible, otherwise curettage and microfractures or mosaicplasty.

  4. Stage IV – Free intra-articular fragment

    Completely detached and displaced osteochondral fragment in the joint (loose body). Empty niche visible on MRI and at arthroscopy. Frequent joint locking. Surgical treatment: loose body extraction, defect filling by microfractures, mosaicplasty or osteochondral autograft depending on defect size. Prognosis depends on residual defect size.

Medical and Surgical Management

  • Conservative treatment (stages I-II, stable fragment, open growth plates): complete sports cessation for 3-6 months, non-weight-bearing activities allowed (swimming). MRI follow-up at 3 and 6 months to assess subchondral bone healing. Healing rate of 50-90% in children with open physis.
  • Arthroscopic fragment fixation in situ (stage II-III, stable fragment of sufficient size): fixation with resorbable screws or pins. Subchondral bed microfractures to stimulate revascularization. Curettage and multiple perforations. Good results rate of 70-85% for fixable fragments.
  • Mosaicplasty (osteochondral autograft): transplantation of osteochondral cylinders harvested from the knee (non-weight-bearing zone) to the capitellum defect. Indicated for medium-sized defects (stage III-IV). Alternative: costal osteochondral graft. Microfractures or autologous chondrocyte graft for small defects.

Physiotherapy treatment

  • Sports rest phase (W0-W12/W24): cessation of the responsible activity (gymnastics, throwing), maintenance of physical fitness through alternative activities (non-weight-bearing cardio, swimming, trunk and lower limb strengthening). Active elbow mobilization within pain-free range to maintain ROM.
  • Range-of-motion recovery: gentle active and active-assisted flexion-extension and forearm rotation. Gentle sustained extension stretching if deficit. No forced passive mobilization or joint loading. Cryotherapy after sessions.
  • Post-operative (after fixation or mosaicplasty): short immobilization (7-14 days), then continuous passive motion (CPM) and early active mobilization. Progressive weight-bearing from week 6-8. Isometric then concentric elbow muscle strengthening from week 8.
  • Progressive return to sport: non-impact activities from week 12-16, then gradual reintroduction of specific sports gestures at week 16-24. Analysis and correction of biomechanical risk factors (throwing technique, training volume). Progressive throwing or weight-bearing return protocol. MRI follow-up before competitive return.

After the session

You may feel slight fatigue or tightness: this is normal. Continue the exercises taught at home to maintain session benefits.

Questions About Elbow Rehabilitation

When should I start physiotherapy after elbow surgery?

Rehabilitation generally begins between 3 and 21 days after the operation, depending on the type of procedure and the stability of the surgical fixation. For fractures treated with stable internal fixation (screw plate), early mobilization is often authorized from D+3 to D+5 to prevent joint stiffness. In cases of elbow replacement or complex ligament repair, the delay may be extended to 2-3 weeks with initial immobilization in a splint. A systematic review published in the Journal of Shoulder and Elbow Surgery confirms that early mobilization after elbow surgery significantly improves final range of motion without increasing the risk of complications [Hackl et al., 2023] . Your surgeon will advise the optimal timing based on your specific procedure.

What are the goals of elbow rehabilitation?

Elbow rehabilitation pursues several complementary goals, adapted to each phase of recovery. In the initial phase (0-6 weeks), the priority is to restore range of motion in flexion-extension (goal: 30°-130° minimum for daily activities) and in pronation-supination (50° in each direction minimum). In the intermediate phase (6-12 weeks), the focus is on progressive muscle strengthening of the flexors, extensors and rotators of the forearm, as well as restoring joint stability through proprioceptive exercises. In the advanced phase (3-6 months), the emphasis is on functional reintegration: daily activities, work tasks and return to sports. Scientific literature highlights that the minimum functional arc of the elbow (30°-130° of flexion-extension, 50° of pronation and 50° of supination) is necessary to perform 90% of daily activities [Mofidi et al., 2020] . Scar treatment and adhesion prevention complete this comprehensive care approach.

Is elbow rehabilitation painful?

The techniques used are progressive and adapted to your tolerance. The elbow is a joint particularly prone to stiffness and inflammatory reactions: overly aggressive rehabilitation can paradoxically worsen the situation by causing heterotopic ossifications (abnormal bone formations in soft tissues). Exercises must be regular but never forced . The physiotherapist always adapts the intensity to stay below the pain threshold, following the "no pain, more gain" rule specific to the elbow. Gentle, regular active mobilization spread across the day in short sequences is generally preferred to prevent stiffness, with early active mobilization recommended after an elbow injury [Akhtar et al., 2021] . Complementary techniques such as cryotherapy , microcurrents and Novafon vibration therapy also help control pain during sessions.

Scientific sources

Average duration

3 to 6 months (conservative), 6 to 12 months (post-surgical), return to sport 9 to 12 months

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