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INTRODUCTION — Osteochondritis dissecans (OCD) refers to osteonecrosis of subchondral bone and was first described by Ambroise Pare in 1558 after finding loose bodies in a patient’s knee. Paget named the process “quiet necrosis” when describing two patients with knee pain in 1870 [1,2]. In 1887 to 1888, Konig was given credit for the original description based on his theory that the loose bodies resulted from a combination of trauma acting on the necrotic lesion underneath.
Konig’s original description was thought to be of inflammatory dissection; however, throughout the years, inflammation was never revealed, making the name osteochondritis a misnomer. Over the next 75 years, multiple physicians noted similar lesions throughout the body. Despite having no evidence of inflammation on histologic examination, the name osteochondritis has prevailed.
OCD most often occurs in the knee, elbow, or ankle of the school-age or adolescent child where it causes pain. Plain radiographs are frequently diagnostic although magnetic resonance imaging is typically necessary to further characterize the lesion. Initial treatment consists of rest, nonsteroidal anti-inflammatory medicines, avoidance of high intensity activities, and physical therapy. Patients who are skeletally immature frequently do well with nonoperative therapy. Patients with large lesions or in whom intraarticular foreign bodies develop usually need surgery.
This topic will discuss the clinical manifestations and diagnosis of OCD. The management of OCD and other causes of knee, elbow, or ankle pain in the young athlete are discussed separately:
DEFINITION — OCD is defined as osteonecrosis of subchondral bone . Specifically, OCD is a localized lesion in which a segment of subchondral bone and articular cartilage separates from the underlying bone, leaving either a stable or unstable fragment that may result in premature osteoarthritis [1,4,5].
There are several classification systems for OCD lesions that are based upon plain radiograph, magnetic resonance imaging, or arthroscopic findings as shown in the table (table 1) [6-8]. On plain radiograph, the severity of the OCD lesion is defined as follows :
●Stage I - Small compressed, nondisplaced fragment
●Stage II - Partially detached fragment
●Stage III - Completely detached, nondisplaced foreign body
●Stage IV - Completely detached and displaced foreign body
PATHOPHYSIOLOGY — The cause of OCD is unknown. Proposed etiologies include repetitive micro-trauma, vascular failure of the vascular architecture at the perichondrium, local ischemia after a single injury, and genetic predisposition [1,9-12].
Juvenile OCD is associated with high activity level in school-age children and adolescents which favors repetitive trauma as a primary mechanism . With initial trauma a focal area of hypovascularity, necrosis, and collapse of the bone develops that can lead to chondromalacia. The necrotic bone is then replaced by subchondral trabeculae or cartilage [13,14]. As the lesion progresses, focal areas of demineralization and repeated shear forces cause detachment of the bone and overlying cartilage. Repeated axial loading with increased valgus or varus stress may play an important role in this phase, particularly in the knee. OCD may also develop after an isolated injury (eg, ankle inversion or direct blow to the knee or elbow).
OCD lesions of the elbow are thought to be, at least in part, due to chronic valgus stress to the elbow which compromises the tenuous blood supply to the capitellum and micro-trauma from chronic compression during overhead activities (eg, throwing, gymnastics) . These repeated injuries cause degeneration of subchondral bone.
OCD lesions can also occur in a familial pattern and have been described in identical twins [15,16]. Thus, genetic predisposition appears to play a role in some patients.
EPIDEMIOLOGY — OCD lesions are a rare cause of joint pain in children. The overall prevalence of OCD lesions, particularly in the knee, is estimated to be 15 to 29 per 100,000 patients [10,17]. In one observational, population-based study of over one million patients, 192 children, ages 6 to 19 years, with OCD were identified, and the disease incidence was 9.5 per 100,000 with patients ages 12 to 19 years . In this study, OCD was more common in males than females (adjusted OR 3.8) and was more common in African Americans than White (adjusted OR 2.0), Hispanic (adjusted OR 5.2), and Asian (adjusted OR 4.2) patients. Repeated trauma or overuse is frequently reported. Sport specific risk factors by anatomic region include sports associated with high frequencies of knee or ankle injuries (eg, soccer, American football, basketball) and, for the elbow, the overhead throwing athlete (eg, baseball pitcher) or gymnast [19,20].
The typical locations of an OCD lesion with relative frequencies are as follows [1,11,21-25]:
●Knee – 75 percent of patients, often occurring in lateral portion of the medial femoral condyle
●Elbow – 6 percent of patients, usually found in the capitellum
●Ankle – 4 percent of patients, particularly the talar dome (57 percent medial and 43 percent lateral)
●Other joints – Approximately 15 percent
OCD typically occurs in patients between the ages of 10 and 20 years although adults can also be affected . Specific age of presentation also depends upon the location of the OCD lesion [1,11,21-25]:
●The prevalence of OCD lesions of the knee peaks in the preteen years, but can occur at any age.
●Osteochondritis dissecans lesions of the elbow are typically found in athletes in the teen years after the physis has closed.
●The ankle OCD lesion is rare in the pediatric population, mainly occurring in adults with the average age being 21 years of age. There is an association with trauma to the ankle, particularly in lateral talar dome lesions.
CLINICAL MANIFESTATIONS — OCD typically presents with pain in the knee, elbow, or ankle that may begin with a specific injury or can develop over several months in highly active patients [9,21,22]. The pain is worsened by exercise. Crepitus, catching, or locking of the joint may occur during the later stages of OCD, especially if a loose foreign body is present in the joint. The diagnosis can frequently be made by clinical findings and judicious use of imaging.
History — The presentations of OCD lesions are dependent on the location, size and severity of the lesion:
●Knee – Early or small OCD lesions found in the knee typically will present with nonspecific, poorly localized knee pain with activity . As the process progresses, gradual onset of stiffness, and intermittent swelling during or after activity occurs [1,9]. When advanced or larger lesions are present, the patient may experience catching or locking, especially if a loose foreign body is present . Loss of range of motion, however, is uncommon.
●Elbow – OCD lesions of the elbow, particularly the capitellum, present with onset of lateral elbow pain that gradually worsens with activity. The pain is often described as dull, is poorly localized to the lateral elbow, and in contrast to patients with OCD of the knee, may be associated with decreased range of motion. Mechanical symptoms of popping, locking, and catching suggest advanced disease.
●Ankle – With OCD lesions of the talar dome, patients typically present with a history of an ankle inversion injury that does not improve with typical conservative treatment . Posteromedial lesions occur when the foot is plantarflexed during inversion, whereas anterolateral lesions occur when the foot is dorsiflexed. Symptoms include pain, persistent swelling, stiffness, weakness, mechanical sensation (eg, popping, clicking, or locking), and with advanced lesions, a loose body sensation (eg, something floating around) in the ankle.
Physical examination — Joint-specific physical examination findings of OCD are as follows:
●Knee – On inspection, swelling may or may not be present. Full range of motion is typically found. The clinician should palpate both femoral condyles for tenderness with the knee in flexion . OCD is suggested by tenderness to palpation with the knee flexed and pressure directed over the medial femoral condyle, just medial to the inferior pole of the patella . Crepitus may also be noted. Patients with chronic symptoms may display an antalgic gait or alteration of gait with the foot of the affected side rotated laterally to reduce the pain of weightbearing [1,3].
The Wilson sign is a provocative test that can identify OCD lesions present at the lateral aspect of the medial femoral condyle and is performed as follows [28-30]: The patient is asked to sit with the knee flexed over the examining table. The knee is then extended actively with the tibia rotated medially. With increasing extension, at approximately 30 degrees of flexion, the pain in the knee should increase. At this point, the patient is asked to stop, rotate the tibia laterally, and the pain disappears. Although helpful in establishing the diagnosis of OCD when present, the Wilson sign is negative in approximately 75 percent of patients with juvenile OCD found on imaging [11,31,32].
●Elbow – Patients with OCD of the elbow often have mild swelling over the capitellum, restricted joint mobility (ie, decreased extension and reduced supination and pronation), tenderness to palpation at the anterolateral aspect of the elbow, and a positive radiocapitellar test characterized by pain with supination or pronation with the elbow in full extension [1,11]. Locking of the elbow suggests formation of a loose foreign body.
●Ankle – Physical examination of the patient with OCD lesions of the talar dome shows tenderness when the ankle is palpated while plantar flexing the ankle to bring the anterior aspect of the articular surface of the talus into the fingertips of the examiner [1,22]. Other findings include swelling and joint effusion in patients with unstable or loose foreign bodies. Range of motion may also be reduced although it is preserved in most patients .
Plain radiographs — Patients with suspected OCD should initially undergo plain radiographs of the affected joint. However, radiographs can be normal, especially in patients with small, compressed fragments (Stage I OCD) (table 1). (See 'Definition' above and "Management of osteochondritis dissecans (OCD)", section on 'Definition'.)
Suggested views and typical findings by joint are as follows:
●Knee – AP, lateral, tunnel, and Merchant (or sunrise) views [32,33].
Most OCD lesions are found on the medial femoral condyle and consist of a subchondral bony fragment surrounded by a crescent-shaped radiolucency (image 1). Tunnel views of the knee often provide the best visualization of the lesions in this location (image 2). Less commonly, lesions may be present on the lateral femoral condyle, femoral trochlea, or patella. Patellar lesions may only be visible on the Merchant (sunrise) view.
●Elbow – AP in full extension, AP in 45 degrees of flexion and a lateral view in 90 degrees of flexion.
Radiographs may demonstrate lateral anterior capitellum flattening or, in more advanced disease, a crater and subchondral sclerosis (image 3).
●Ankle – Oblique, mortise, and plantar flexed views [1,34].
Initial radiographs are normal in approximately one-third of cases . Medial dome OCD of the talus is seen best on the anteroposterior (AP) view of the ankle in maximal plantarflexion and appears as a deep, cup-shaped lesion (image 4). Lateral lesions are best seen on the mortise view with the ankle in dorsiflexion. These lesions are shallow and wafer-like.
Based upon small case series, we suggest radiographic views of both knees and ankles regardless of symptoms because bilateral disease is found in up to 25 percent of patients [25,36]. Furthermore, comparison views with the contralateral knee help differentiate OCD from normal variations in ossification of the femoral condyles in skeletally immature patients .
In our experience and as described in case reports, contralateral radiographs when assessing patients for OCD of the elbow are unnecessary unless patients report bilateral pain [37-39].
Magnetic resonance imaging — Evidence for the use of MRI in the evaluation and management of OCD is limited to small observational studies and expert opinion [10,24,32,40-43]. MRI has the capability of assessing the surrounding cartilage and subchondral bone that is not seen on plain radiographs .
●Indications and type of study – MRI is the imaging study of choice for diagnosis of OCD in patients with normal plain radiographs but persistent symptoms and for grading of lesions in patients with OCD demonstrated on plain radiographs. In most instances, MRI without contrast provides adequate diagnostic and staging information. In patients for whom stability of the lesion is uncertain, gadolinium contrast can help determine if blood supply to the bony fragment is adequate [1,24]. In younger children, MRI also helps to differentiate normal ossification centers of the distal femur from OCD .
MRI has similar utility for establishing the diagnosis of OCD in the elbow and ankle. MRI can be especially helpful in symptomatic patients in whom plain radiographs are normal. MRI also provides a means to identify unstable lesions in these joints [24,40]. In patients with capitellar OCD, MRI is particularly helpful for identifying cartilaginous foreign bodies that are usually missed by plain radiographs . In patients with OCD lesions of the dome of the talus, MRI has been useful for both preoperative evaluation and follow-up examination.
MRI is less useful for determining healing of OCD lesions because clinical healing may not correlate with imaging [9,22], and in patients with operative repair, bony edema from instrumentation interferes with identification of healing during the postoperative period .
●Clinical correlation – The correlation between MRI findings and those seen on arthroscopy vary by skeletal maturity:
•Skeletally mature – In skeletally mature patients (adult OCD), MRI of the knee is typically performed to further characterize lesions found on plain radiograph . This approach permits grading (table 1) and provides information regarding the stability of the bony fragment. Limited evidence suggests that MRI has high diagnostic sensitivity and specificity (100 percent for both in small observational studies) for OCD and is also concordant with arthroscopic findings with respect to bone fragment stability . Thus, MRI appears useful for confirming the diagnosis and determining the need for surgery in patients with adult OCD.
•Skeletally immature – By contrast, MRI findings in skeletally immature patients (juvenile OCD) require careful clinical correlation and should not be solely relied upon to determine the need for operative treatment. In these patients, MRI also has a high diagnostic sensitivity (approximately 100 percent), but diagnostic specificity is low (approximately 10 to 15 percent) and predicted stability of the bony fragment lacks concordance with arthroscopic findings in up to 70 percent of patients . Specifically, Stage III lesions on MRI (large signal behind the bony fragment), frequently have normal surface cartilage with no fragment instability on arthroscopy .
Other imaging — Computed tomography (CT), single photon emission computed tomography (SPECT), ultrasound (US), and radionuclide bone scan have all been used in the evaluation and management of OCD [40,45-50]. However, in most patients, plain radiographs and, if indicated, magnetic resonance imaging are sufficient to establish the diagnosis of OCD and, along with clinical findings, determine further management.
●Computed tomography and single photon emission computed tomography – In some patients with loose intraarticular bony foreign bodies, especially involving the talus, CT may aide in characterizing the location and appearance of the bony fragment for surgical planning and management [40,48]. After surgery, conventional CT and SPECT can theoretically provide information about the metabolic state in bone healing and how well the bone fragment is being integrated during the time period when bony edema from the repair interferes with MRI results [45,49]. However, the use of CT and SPECT for this indication is not routine and requires further study.
●Ultrasound – Ultrasound in the hands of experienced operators can identify OCD lesions of the knee and elbow and provide information on stability [47,51]. As an example, in a small case series of 27 patients between 11 and 20 years of age with capitellar OCD, US identified unstable lesions that were confirmed in 14 of 15 patients at arthroscopy . However, US is not routinely used or available for this purpose and provides information that is inferior to MRI.
●Radionuclide bone scan – Radionuclide bone scans have largely been replaced by MRI for the diagnosis of OCD in symptomatic patients with normal plain radiographs because of radiation exposure and limited information provided by the images. When compared to MRI, bone scans do not give detailed information about the anatomy of the bone or the articular cartilage which would be necessary for classification and therapeutic planning . Furthermore, the radionuclide tracer from a bone scan remains in the lesion for long amounts of time, even after the lesion has healed, thus limiting the ability to determine resolution of the condition .
DIAGNOSIS — Suggestive clinical findings of OCD include gradually worsening joint pain over several months in active patients or, for OCD of the talus, lingering pain after an ankle inversion injury. Bony tenderness over the typical locations (medial femoral condyle, anterolateral elbow, or medial or lateral talar dome), or, with advanced disease, popping, catching, or locking of the joint may be elicited. The diagnosis of OCD can frequently be made based upon plain radiographic findings of the characteristic bony fragment (image 2 and image 3 and image 4). (See 'Clinical manifestations' above.)
In patients with typical clinical and radiographic findings of OCD, magnetic resonance imaging is not needed to establish the diagnosis but may be helpful in determining further management. Magnetic resonance imaging may be necessary for diagnosis of OCD in patients with normal plain radiographs but persistent characteristic symptoms or to differentiate OCD from other joint derangements. (See 'Magnetic resonance imaging' above and 'Differential diagnosis' below.)
DIFFERENTIAL DIAGNOSIS — Several conditions have clinical features that overlap with OCD. Most can be identified by a careful history and physical examination and plain radiographs.
Torn meniscus — Meniscus tears are typically acute in nature and have a known or suspected mechanism of injury. However, in older patients the suspected mechanism may be a minor movement resulting in pain and swelling, versus an adolescent patient in which the traumatic event is likely to be more obvious. Meniscal tears typically occur when the knee twists with the foot fixed during activities, such as football (soccer), American football, and basketball. Pain and swelling vary depending upon the size of the tear and joint effusion is common.
Patients with meniscal tears often have joint line tenderness, inability to fully extend the knee, inability to squat or kneel, and have discomfort with provocative tests such as the Thessaly test (standing on one leg with the knee flexed to 20 degrees followed by internal and external rotation of the knee) or McMurray maneuver (picture 1). Patients with OCD may have some of these findings depending on the site of the OCD lesion. (See "Meniscal injury of the knee", section on 'Mechanism and presentation' and "Meniscal injury of the knee", section on 'Physical examination' and "Meniscal injury of the knee", section on 'Diagnosis'.)
Symptomatic discoid meniscus — Some individuals are born with a variant meniscus in the shape of a disk. Although most commonly asymptomatic, a discoid meniscus can cause clicking, popping or catching with pain over the lateral joint line (the "snapping knee syndrome") . A tear in a discoid meniscus may also be accompanied by effusion and clinical findings of meniscal tears including decreased knee extension, inability to squat or kneel, and discomfort with provocative tests. Magnetic resonance imaging or diagnostic arthroscopy can confirm the diagnosis. By contrast, OCD typically causes medial knee pain and does not affect knee range of motion.
Medial plica syndrome — Medial plica syndrome involves irritation of the synovial remnant in the knee, which can become inflamed with repetitive trauma. Patients complain of catching or popping along with nondescript knee pain on the medial joint.
Tenderness is typically found over the medial aspect of the knee. Careful palpation with the knee at 90 degrees of flexion may reveal a firm, tender ridge of tissue running either parallel or slightly obliquely to the medial border of the patellar which helps to differentiate OCD from plica syndrome. Examination may also reveal tight quadriceps and hamstring muscles and positive medial patellar plica (figure 2) and knee extension (figure 3) tests which are negative in patients with OCD.
Arthroscopy provides a definitive diagnosis if a thickened, fibrotic plica is demonstrated, but is only performed when other diagnoses are considered or when conservative treatment fails. (See "Plica syndrome", section on 'Diagnosis'.)
Patellofemoral pain — Patellofemoral pain is a clinical diagnosis that is suggested by a dull, diffuse anterior knee pain that is worsened by activity, squatting, using stairs, or prolonged sitting and often occurs in runners. Unlike OCD, the physical examination shows varying degrees of patellar misalignment, pain with squatting, and pain with resisted quadriceps contraction. In addition, special tests for patellofemoral pain (eg, patellofemoral compression test, patellar glide, or apprehension test) are frequently positive. The performance of these tests are discussed in detail separately. (See "Patellofemoral pain", section on 'Special tests'.)
Panner disease — Panner disease is an osteochondrosis characterized by atypical ossification, necrosis, and regeneration of the distal humeral capitellum epiphysis and secondary ossification centers. It occurs most frequently in boys between 7 and 10 years of age and is almost always unilateral and in the dominant (ie, throwing) arm. The pain increases with continued throwing and decreases with rest. Radiographs typically show fragmentation (areas of sclerosis and rarefaction) of the capitellum with an irregular joint surface similar to OCD. In contrast to OCD of the elbow, Panner disease occurs in school-age children as opposed to adolescents and does not produce a loose foreign body. Management of Panner disease is discussed separately. (See "Elbow injuries in active children or skeletally immature adolescents: Approach", section on 'Panner disease'.)
Little league elbow — Little league elbow specifically relates to apophysitis of the medial epicondyle due to repeated valgus stress. This condition frequently occurs in throwing athletes, particularly pitchers. When compared to OCD, physical examination typically demonstrates medial epicondyle pain rather than anterolateral pain and the radiocapitellar compression test is negative. Radiographs are typically normal. (See 'Physical examination' above and "Elbow injuries in active children or skeletally immature adolescents: Approach", section on 'Medial elbow pain'.)
Medial epicondyle fracture — Avulsion fractures typically occur after a fall on an outstretched hand. Patients may experience a pop with acute swelling. Radiographs should be obtained, showing the avulsion fracture which differentiates this injury from OCD (image 5). The treatment of these fractures is discussed in greater detail separately. (See "Epicondylar and transphyseal elbow fractures in children", section on 'Medial epicondylar fractures'.)
Epicondylitis — Lateral (tennis elbow) or medial epicondylitis (golfer’s elbow) can present in the pediatric population, but is more commonly seen in adolescents and adults. Lateral epicondylitis presents with pain at the lateral epicondyle where the extensor carpi radialis brevis inserts. Medial epicondylitis presents with pain medially where the flexor and pronator muscles insert. Unlike OCD, epicondylitis is not associated with locking and the capitellum is unaffected. Plain radiographs are typically normal. (See "Epicondylitis (tennis and golf elbow)", section on 'Clinical presentation and examination'.)
Ankle sprain — Similar to OCD, ankle sprains often arise from inversion injuries and cause lateral or medial ankle pain. The anterior talofibular ligament is most commonly involved. Physical examination demonstrates pain and swelling over the ligamentous complex. Depending upon the degree of sprain, ligamentous laxity may be noted on anterior drawer and talar tilt tests. Ankle sprains differ from OCD by their resolution over several weeks and by the absence of bony findings on plain radiographs. The clinical features and treatment of ankle sprains are discussed in greater detail separately. (See "Ankle sprain".)
Os trigonum — The os trigonum is the persistence of the lateral ossification center on the posterior aspect of the talus after skeletal maturation. The groove for the flexor hallucis longus on the posterior aspect of the talus has an elongated lateral wall called Stieda's process. The os trigonum can cause pain during activities requiring repetitive plantar flexion (eg, swimming, gymnastics, dancing); although, patients with this condition are frequently asymptomatic.
Patients with os trigonum syndrome describe pain in the posterior lateral aspect of the ankle; symptoms may be exacerbated when walking downhill. Tenderness is present at the posterolateral aspect of the ankle. Pain is accentuated by squatting, resisted plantarflexion, or dorsiflexion of the great toe because these maneuvers cause the flexor hallucis longus (FHL) to push against the ossicle as the FHL passes over the talus. Plantarflexion of the foot with axial loading to the heel reproduces the symptoms. Plain radiographs (lateral ankle and lateral ankle in plantar flexion) demonstrate the presence of the os or Stieda's process. Os trigonum differs from OCD by the location of pain (posterior instead of medial or lateral) and by radiographic findings. (See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Os trigonum syndrome (posterior ankle impingement)'.)
Tarsal coalition — Tarsal coalition, a fibrous bony connection between two or more of the tarsal bones, is a condition that is present at birth but becomes symptomatic only during the second decade as the coalition(s) ossify. Calcaneonavicular and talocalcaneal coalitions are most common and typically occur bilaterally (figure 4). Ossification limits motion at the tarsal joint. Patients may complain of pain over the subtalar joint of the foot. The pain worsens with activity, walking on uneven ground, or running. Physical examination findings include a rigid flatfoot, hindfoot valgus, loss of subtalar motion, and limited, painful inversion of the foot. However, these findings are not specific and may overlap with clinical findings of OCD. Tarsal coalition can be differentiated from OCD by oblique radiographs or computed tomography (CT) scan of the subtalar joint which demonstrate the bony coalition (image 6).
MANAGEMENT — The management of OCD is discussed separately. (See "Management of osteochondritis dissecans (OCD)".)
●OCD is a localized lesion in which a segment of subchondral bone and articular cartilage separates from the underlying bone, leaving either a stable or unstable bone fragment. OCD may result in premature osteoarthritis. (See 'Definition' above and "Management of osteochondritis dissecans (OCD)", section on 'Definition'.)
●OCD lesions are a rare cause of joint pain in children and are associated with repeated trauma or overuse in athletes. Boys are affected about two to three times as often as girls. The knee is most commonly affected followed by the elbow and ankle. (See 'Epidemiology' above.)
●OCD typically presents with pain in the knee, elbow, or ankle that may begin with a specific injury or can develop over several months in highly active patients. The pain is worsened by exercise. Crepitus, catching, or locking of the joint may occur during the later stages of OCD, especially if a loose foreign body is present in the joint. History and physical examination findings vary by the involved joint. (See 'Clinical manifestations' above.)
●Patients with suspected OCD should initially undergo plain radiographs of the affected joint. OCD lesions consist of a subchondral bony fragment surrounded by a crescent-shaped radiolucency and vary in location depending upon the involved joint (image 1 and image 4 and image 3). (See 'Plain radiographs' above.)
●Magnetic resonance imaging (MRI) is suggested for the diagnosis of OCD in patients with normal plain radiographs but persistent symptoms and for grading of lesions in patients with OCD demonstrated on plain radiographs (table 1). (See 'Magnetic resonance imaging' above.)
●The diagnosis of OCD can frequently be made based upon plain radiographic findings of the characteristic bony fragment (image 2 and image 3 and image 4). Suggestive clinical findings include gradually worsening joint pain over several months in active patients or, for OCD of the talus, lingering pain after an ankle inversion injury. Physical findings consist of bony tenderness over the typical locations (medial femoral condyle, anterolateral elbow, or medial or lateral talar dome), or with advanced disease, popping, catching, or locking of the joint. (See 'Diagnosis' above.)
●Several conditions have clinical features that overlap with OCD. Most can be identified by a careful history and physical examination and plain radiographs. (See 'Differential diagnosis' above.)
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