As the natural history is not known for all OCD types, there is some controversy about whether any can be managed symptomatically, perhaps with rehabilitation to improve muscle strength, range of movement and proprioception, or with protection in a cast or brace.
Early series treated most low-grade lesions non-surgically and reported a reasonable number of good results. Elias (2006) reported 29 patients who had non-interventional follow-up for 10-35 months with follow-up MRIs. 13 progressed, 7 improved and 9 remained unchanged. Most of the changes would have lead to re-classification on most of the existing classification systems. All subchondral cysts improved, and bone marrow oedema improved in 7 patients, deteriorated in 10 and developed anew in 2. Ankle OA appeared dusing follow-up in 2 patients and deteriorated in 1.
Shearer (2002) reported satisfactory results in half of 35 ankles with chronic “stage 5” cystic lesions (Bristol stage 5), with few developing OA. Follow-up ranged from 4 months to 20 years, and only six patients opted for surgery, all within 2 years.
There have been no RCTs comparing surgical to non-surgical treatment for any grade of OCD. However, Tol (2000) conducted a systematic review of reports of treatment outcomes up to then and found that only about half of patients treated non-surgically got good results, compared with about 80% after arthroscopic treatment of various types
We therefore normally advise arthroscopic debridement for symptomatic osteochondral lesions. Occasionally patients decline surgery or have asymptomatic lesions discovered while investigating other complaints. In these situations we do not restrict activities but recommend repeat MRI after about a year.