Conservative Management of Knee Pain Associated With a Benign Femoral Osteochondroma in a Youth Athlete: A Case Report

Abstract

Objective

The purpose of this case report is to describe the conservative treatment of a patient with musculoskeletal knee pain associated with a benign femoral osteochondroma.

Clinical Features

An 11-year-old boy with acute left knee pain for 1 week's duration presented for chiropractic evaluation. He attributed the pain to nontraumatic provocation during football and a pre-existing benign osteochondroma located in his left femoral epiphysis. He had pain throughout his posteromedial knee and distal thigh, attributed to acute irritation of the surrounding adductor and medial hamstring musculature. His orthopedic surgeon had recommended delaying surgical excision. The patient presented for conservative pain management to continue participating in football.

Intervention and Outcome

A trial of conservative care was performed for 3 visits throughout 6 days. It consisted of therapeutic exercise in the form of end-range isometric exercises and gentle manual therapy, with self-management strategies including Kinesio Taping and cryotherapy. After 3 visits the patient's acute pain declined and his function and ranges of motion returned to baseline, which allowed him to continue participating in youth football unrestricted.

Conclusion

A young athlete with knee pain, likely associated with a distal femoral osteochondroma, was managed with a short course of chiropractic care. The patient was able to continue participating in youth football and required no further care.

Introduction

An osteochondroma is a benign, skeletal protrusion with a hyaline cartilaginous cap that acts as the growth site.^1,2 Osteochondromas are most commonly found in the distal femur, as presented in this case report, and tend to favor the metaphysis of long bones, but they can also occur on any bone in the body.^1,3,4 The syndrome of hereditary multiple exostosis involves multiple osteochondromas, but the main focus of this case report will be solitary osteochondromas. Many solitary osteochondromas may be incidentally found in asymptomatic individuals later in life, but 75% to 80% of symptomatic osteochondromas are diagnosed before the age of 20 years.¹ This is significant because although surgical resection is accepted as the optimal treatment, it is not without risk of complication or recurrence. This plus the eventual cessation of growth in both the patient and the osteochondroma simultaneously is why surgical options are commonly postponed until after the patient has reached skeletal maturity.^3,5,6 Depending on the symptomatology, the majority of patients will exhaust conservative and supportive measures first.^1,3 Unfortunately, there is a lack of documented specific conservative-care interventions or prognoses related to musculoskeletal complications of osteochondroma represented in the literature.

Complications documented from osteochondromas include—but are not limited to—vascular injury, peripheral nerve impingement, and fracture.^{1, 2, 3, 4, 5} The range of musculoskeletal complications from osteochondromas relates largely to the size and location of the bony growth. Hereditary multiple exostosis does appear to be represented most commonly in the literature as causing complications, as opposed to a single osteochondroma.

Musculoskeletal complications from osteochondromas range from mild to severe. These include cases as emergent as knee locking, which required general anesthesia for tumor excision and exploratory surgery of the soft tissues that revealed the semitendinosus tendon confined inferior to the osteochondroma.⁷ Another reported complication is limb deformity.⁶ Tendon “snapping” of the surrounding musculature, mechanical joint restrictions of movement, and tendinopathy have been most frequently reported.^{3,5,8, 9, 10, 11}

Many of these reported cases with musculoskeletal complications were treated with surgical intervention. There was 1 case report in which the patient opted for conservative care for her vastus medialis pain related to an osteochondroma in her distal femur, but no conservative-care measures were stated. As far as the author is aware, there have been no reported conservative-care management protocols or prognoses for musculoskeletal complications accompanying osteochondromas. It has been suggested that best practices include conservative care to manage symptoms until the patient reaches skeletal maturity, but no conservative-care trials for musculoskeletal management of osteochondromas have been published.^3,5,6

Therefore, the purpose of this case report is to describe a course of chiropractic care for the management of musculoskeletal pain associated with a benign osteochondroma to allow the delay of surgery until the patient was skeletally mature.

Case Report

An 11-year-old boy with acute left knee pain for 1 week's duration presented to the chiropractic clinic for evaluation. He attributed the pain to provocation during football practice that was nontraumatic in nature. He located the pain along his medial and posterior left knee and distal thigh. He had a known benign osteochondroma in the epiphysis of his left distal femur, the same location of his acute pain. He was being closely monitored by his physician with regular imaging but had not been deemed a surgical candidate at that time, due to his age and the location of the tumor in the active growth plate (Fig 1).

Fig 1.

Anteroposterior-view radiograph of the left knee, demonstrating a distal femoral osteochondroma.

There was minimal swelling visible upon observation, without discoloration or bruising. He presented with intermittent pain, rated 5 out of 10, during specific movements and muscular contractions, and 0 out of 10 while at rest. A bony prominence that was assumed to be the osteochondroma was palpable, with point tenderness noted both in the soft tissue directly overlying it and throughout his adductors and medial hamstring musculature. The patient was neurologically intact, with 5 out of 5 myotome strength noted throughout the lower extremities, 2+ deep tendon reflexes at L4 and S1 bilaterally, and sensation intact and symmetrical. Active thoracolumbar ranges of motion were moderately decreased in flexion that was able to provoke pain in the left hamstring. All other thoracolumbar ranges were within normal limits and not painful. Left passive and active knee flexion were mildly reduced, with pain in the soft tissue directly overlying the bony prominence and throughout the medial hamstring. All other knee ranges were within normal limits and nonprovocative to pain. There were no significant orthopedic test findings.

It was hypothesized that due to the large size and location of the osteochondroma, paired with the patient's activity level as a youth football athlete, the bony prominence had likely aggravated the surrounding musculature in both the aforementioned adductor and hamstring musculature. Consideration was given to the patient's young age and the pain he was feeling in guiding treatment.

During the first visit, the patient was unable to tolerate manual therapy. He was treated with controlled body-weight isometric holds to target the affected musculature, with the duration determined by his tolerance. This was performed at the tolerated end range of left knee flexion, left hip extension, left hip flexion, and left hip abduction. For a more tolerable way to introduce eccentrics, the patient would hold the isometric position to tolerance and then slowly release the position. He was encouraged to self-manage with cryotherapy until his next visit and to withdraw from football practice temporarily.

The patient returned to the clinic the next day with pain rated 3 out of 10, stating that he was feeling “much better” and had adhered to the self-management suggestions. He presented for treatment before returning to modified football practice that evening. He had improved ranges of motion in thoracolumbar flexion, with continued pain in the left medial hamstring. His other ranges of motion in the knee remain unchanged.

During the second treatment, he received another series of the same exercises, with a focus on improving the duration of isometric holds and increasing the end-range tolerance. On that visit, he could better tolerate gentle manual therapy around the surrounding musculature. He received Kinesio Taping for practice along his adductors and medial hamstrings overlying the osteochondroma. He was encouraged to continue the same self-management strategies at home until his next visit.

He presented for his final visit 4 days later with reduced pain, largely 0 out of 10, only with minor provocation with compression of the soft tissue directly overlying the bony prominence. His thoracolumbar flexion was nearly full, which he stated was his usual range, with only minor hamstring irritation. He had improved knee flexion, both active and passively. He continued self-management, noting great relief with the Kinesio Taping. He had returned to full-contact practice without provocation. He was treated at his final visit with the same aforementioned exercises and manual therapy.

He was able to be discharged to an as-needed basis for any future episodes of acute pain, but 6 months later had still not returned to the clinic. The patient's parent provided consent for this report to be published.

Discussion

This is the first case to describe a conservative-care approach that was successful in improving function and reducing pain surrounding a patient's nonsurgical femoral osteochondroma. Additionally, this is the first case of its nature to be published in the chiropractic literature. However, isometric and eccentric loading with or without manual therapy has been historically used to treat a wide range of tendinopathies.^{12, 13, 14} More specifically, isometrics have been found to be superior for short-term pain relief, whereas eccentrics have shown better long-term pain reduction and improved function.¹³

Up to 75% to 80% of symptomatic osteochondromas are diagnosed before the age of 20 years.¹ However, due to the eventual cessation of tumor growth with skeletal maturity and the risk of surgical complications or subsequent recurrence, it is an accepted standard of practice to delay surgical excision if possible.^3,5,6 Depending on the symptomatology, the majority of patients are encouraged to exhaust conservative-care measures first.^1,3 However, there is a gap in the published literature that discusses conservative-care interventions or expected prognoses for those with musculoskeletal complications associated with a benign osteochondroma. To the author's knowledge, there is currently only 1 other case report published in which the patient pursued conservative care over surgical intervention, but in that report there is no treatment plan, prognosis, or outcome stated.³

This case portrays the conservative treatment plan with specific interventions for a young patient with a symptomatic benign femoral osteochondroma provoking acute musculoskeletal pain. It demonstrates that 3 visits over 6 days, plus self-management strategies, assisted the patient in returning to baselines on pain score and function, as well as returning him to football unrestricted and delaying surgical intervention.

Limitations

These results are representative of a single case and may not be applicable to every patient with musculoskeletal complications associated with a benign osteochondroma. Due to the complaint persisting for only 1 week prior to treatment, spontaneous resolution without care might have been probable as well.

Conclusion

The young athlete in this case was treated with 3 visits of chiropractic care and he experienced sustained relief of knee pain likely associated with a distal femoral osteochondroma. He was able to continue participating in youth football and required no further care.