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| Orthopaedic Health Encyclopedia |
Ankle Fracture
The ankle is comprised of three bones, one of which (the talus) sets inside a cavity formed by the other two (the tibia and the fibula). Each one is joined to the other by a short ligament. Any of these ligaments may be torn (sprained) or the bones may break (fracture) where the ligaments attach. This usually occurs in response to a twisting injury.
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Most sprains and some fractures may be treated by immobilization alone (i.e., casts, splints or fracture boots), but some may require surgical intervention. When a fracture (break) occurs along a joint surface, the corresponding pieces must heal in a nearly anatomic position to lessen the chances of developing a traumatic arthritis.
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| Ankle Sprain
The ankle sprain is the most common sports injury and generally occurs in activities which involve running and jumping (i.e. basketball, soccer and volleyball).
Ankle sprains are generally classified in 3 categories:
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- Grade I - These involve a stretched ligament with minimal swelling and pain.
- Grade II - A partial tear of the ligaments occurs with moderate pain and swelling.
- Grade III - Complete tear of the ligament with instability, frequent and disabling pain and marked edema (swelling) and discoloration.
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Most patients will give a history of a “twisting” injury and will have difficulty weight bearing initially on the injured foot. Swelling will appear immediately or gradually over 3 to 4 hours. Other patients report they are “apprehensive” about bearing weight on the involved foot.
A sports medicine physician will usually order X-rays to confirm or rule out a broken bone and to evaluate for joint instability.
Generally, grade I or II sprains will be treated functionally with a brief period of controlled immobilization. Icing, elevation and compression are of paramount importance during the rehabilitation period. These components will aid in the reduction of the inflammatory response.
In a grade III sprain, casting or surgical repair are considered depending upon the severity of the injury. Grade I and II ankle sprains tend to recover within a short time frame and progress is usually noted within 2 weeks. A grade III ankle sprain will take a longer period of time to heal depending upon the severity of the injury. With a strong rehabilitation program, carefully undertaken, patients may gradually resume normal activities over a 6 week period.
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| Lateral Epicondylitis
This is an inflammation of the area where a muscle group attaches to the elbow. It may be caused by overuse, but generally its cause is unknown.
Symptoms include pain in the elbow or proximal (link) forearm and possibly some weakness. X-rays are often taken to evaluate any possible bony abnormalities in the area.
Treatment consists of ice, immobilization, a course of anti-inflammatory medication and possibly a steroid injection to alleviate the symptoms of this persistent malady.
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| Deep Venous Thrombosis (DVT)
This is a condition in which blood abnormally clots in your veins. It may be caused by a fracture, immobility for any reason, certain drugs (e.g., birth control pills) and obesity.
Symptoms include pain isolated to one leg (usually in the calf or medial thigh) or swelling in the extremity.
This can be a medical emergency and you should consult a medical doctor immediately. Diagnosis may be confirmed by ultrasound or by a venogram. A venogram includes the injection of contrast dye into your vein followed by a series of x-rays which can demonstrate narrowing or blockage within the vein.
Treatment may include elevation, the application of heat packs to the affected area and blood thinning medications (such as Heparin or Warfarin).
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Night Cramps
These involve spasmodic muscle cramping of an unknown etiology (cause) which occurs primarily at night. The most commonly affected muscles are the calf and thigh.
Massage and static stretching may be of some help in decreasing the pain of night cramps but there is no proven preventative measure.
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| Avascular Necrosis
Avascular necrosis (also referred to as aseptic necrosis or osteonecrosis) is a disease that results from poor blood supply to an area of bone causing bone death. This is a serious condition because the dead areas of bone do not function normally, are weakened, and can collapse. Pain associated with avascular necrosis is often severe and unrelenting.
Causes:
Avascular necrosis can be caused by trauma and damage to the blood vessels that supply bone its oxygen.
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Other causes of poor blood circulation to the bone include an embolism of air or fat that blocks the blood flow through the blood vessels, abnormally thick blood (hypercoagulable state), and inflammation of the blood vessel walls (vasculitis).
Risk Factors:
Conditions that are associated with avascular necrosis include alcoholism, steroid usage, Cushing’s syndrome, radiation exposure, sickle cell disease, pancreatitis, Gaucher’s disease, and systemic lupus erythematosus.
Diagnosis
The diagnosis of aseptic necrosis can be made with x-rays, but this is a later stage finding. Earlier signs of avascular necrosis can be detected with MRI scanning or suggested by nuclear bone scanning.
Treatment
The treatment of aseptic necrosis is critically dependent on the stage of the condition. Early avascular necrosis (before x-ray changes are evident) can be treated with a surgical operation called a core decompression. This procedure involves removing a core of bone from the involved area and sometimes grafting new bone into the area. This allows new blood supply to form, preserving the bone. Weight bearing should be restricted.
Later stages of avascular necrosis (when X-ray changes have occurred) inevitably lead to seriously damaged bone and joints and requires joint replacement surgery.
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What is Bursitis
A bursa is a closed fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. The major bursae (plural for bursa) are located adjacent to the tendons near the large joints, such as the shoulders, elbows, hips, and knees. When the bursa becomes inflamed, the condition is known to as “bursitis.” Most commonly, this is a non-infectious condition (aseptic bursitis) caused by inflammation resulting from local soft tissue trauma or strain injury. On rare occasions, the hip bursa can become infected with bacteria. This condition is called septic bursitis.
What is Hip Bursitis
There are two major bursae of the hip, which can both be associated with stiffness and pain around the hip joint.
The trochanteric bursa is located on the side of the hip. It is separated significantly from the actual hip joint by tissue and bone. Trochanteric bursitis frequently causes tenderness of the outer hip, making it difficult for patients to lie on the involved side. It also causes a dull, burning pain on the outer hip that is often made worse with excessive walking or stair climbing. Sufferers often experience excruciating pain when getting up from a sitting position, but feel better after moving around a little bit.
The ischial bursa is located in the upper buttock area. It can cause dull pain in this area that is most noticeable climbing up hill. The pain sometimes occurs after prolonged sitting on hard surfaces, hence the names “weaver’s bottom” and “tailor’s bottom.”
Treatment
The treatment of any bursitis depends on whether or not it involves infection. Aseptic hip bursitis can be treated with ice compresses, rest, and anti-inflammatory and pain medications. Occasionally, it requires aspiration of the bursa fluid. This procedure involves removal of the fluid with a needle and syringe under sterile conditions. It can be performed in the doctor's office. Sometimes the fluid is sent to the laboratory for further analysis. Non infectious hip bursitis can also be treated with an injection of cortisone medication into the swollen bursa. This is sometimes done at the same time as the aspiration procedure. Generally, patients should avoid hills and stairs, when possible, while symptoms are present.
Septic bursitis requires even further evaluation by a doctor. This is unusual in the hip bursa, but does occur. The bursal fluid can be examined in the laboratory for the microbes causing the infection. Septic bursitis requires antibiotic therapy, often intravenously. Repeated aspiration of the inflamed fluid may be required. Surgical drainage and removal of the infected bursa sac (bursectomy) may also be necessary.
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Osteoarthritis of the Hip
Osteoarthritis of the hip develops slowly and often involves both sides of the body. Men are more frequently afflicted than women. Osteoarthritis of the hip can cause insidious pain in the groin or inguinal region and, on occasion, pain in the side of the buttock or upper thigh. Often, osteoarthritis of the hip can cause you to walk with a limp. You will find that the pain is aggravated when you are moving, and relieved when you rest. Proper gait training, walking aids, and medication can be very effective in controlling symptoms.
What is Osteoarthritis?
Osteoarthritis (OA) is most commonly marked by degeneration of the cartilage, which is the resilient connective tissue that lines the ends of the bones and forms the surface of the joint. Normal cartilage absorbs shock (which might otherwise injure the hard bones) and allows movement of the joints along its smooth, slightly lubricated surface. In addition to cartilage damage, the bone may enlarge (called hypertrophy) at the ends, and there may be some changes in the synovial membrane, a thin tissue that lines the capsule surrounding the joint. Abnormal projections of bone, called osteophytes, may develop as well.
The joints most commonly affected by osteoarthritis include knees, the smaller joints of the fingers, the hips, the joints of the big toes, and those of the lower part of the spine. Osteoarthritic involvement of the wrists, elbows or shoulders is rare, except after severe injury. The degeneration of the joint may occur as a result of injury or trauma to the joint, rheumatoid arthritis, occupational overuse, obesity, or metabolic diseases.
OA is the most common form of arthritis. It may first appear without symptoms between 20 and 30 years of age and is present in almost everyone by the age of 70. Symptoms generally appear in middle age. Both men and women are equally affected by osteoarthritis, which is also called degenerative joint disease (DJD). However, under age 45, the prevalence of osteoarthritis is greater among men, where over age 55, the prevalence is greater for women. Approximately 40 out of 100 people are affected.
Symptoms:
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Gradual and subtle onset of deep aching joint pain |
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Worse after exercise or weight bearing |
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Often relieved by rest |
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Limited movement |
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Grating of the joint with movement |
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Painful bony growths in the joints |
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Pain often centered in the groin |
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Treatment:
A treatment program should have the following goals: easing pain and discomfort, reducing or preventing disability, and helping you continue your usual activities as independently as possible. Most doctors begin by recommending a combination of medicine plus exercise and rest. Medicine can be very helpful in reducing pain. If you can move without pain, or with less pain, you will be able to keep moving better and longer.
Regular exercise helps strengthen the muscles that support the joints. The stronger those muscles are, the more comfortable you will be. Rest is also necessary, to relax the muscles and to keep you from overusing painful joints. With rested muscles, you can exercise better, too. Therefore, a good balance of exercise and rest is needed.
Your particular treatment program will also depend on which and how many of your joints are affected, how far the disease has progressed, and what you want to do and can do. Your program will be individualized — that is, tailored specifically for you. It may not be the same as someone else’s. You and your doctor will work together at finding the right combination for you, so be sure to say something if you think any part of the plan is not helping. Changes can be made. You may want help from others, too, such as a nurse or physical therapist. Talk about these possibilities with your doctor.
First line treatment includes modification of activity and use of an anti-inflammatory medicine. Sensitivity of the stomach and intestines many times makes prolonged use of the anti-imflammatory medicines difficult. When the condition becomes particularly severe, then surgery is indicated. The most common procedure is Total Hip Replacement which aims at resurfacing both the cup (acetabulum) and ball (femoral head) surfaces. A frequent misconception of patients is that they are too old for this type of surgery since it is extensive. However, the vast majority of patients undergoing hip replacement surgery are easily within the retirement age group and usually do excellently.
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Total Hip Replacement
A total hip replacement is a surgical procedure whereby the diseased cartilage and bone of the hip joint is surgically replaced with artificial materials. The normal hip joint is a ball and socket joint. The socket is a “cup-shaped” bone of the pelvis called the acetabulum. The ball is the head of the thigh bone (femur).
Total hip joint replacement involves surgical removal of the diseased ball and socket, and replacing them with a metal ball and stem inserted into the femur bone and an artificial plastic cup socket. The metallic artificial ball and stem are referred to as the “prosthesis.” Upon inserting the prosthesis into the central core of the femur, it is fixed with a bony cement called methylmethacrylate. Alternatively, a “cementless” prosthesis is used which has microscopic pores that allow bony in growth from the normal femur into the prosthesis stem. This “cementless” hip is felt to have a longer duration and is considered especially for younger patients.
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Who is a Candidate for Total Hip Replacement?
Total hip replacements are performed most commonly because of progressively severe arthritis in the hip joint. The most common type of arthritis leading to total hip replacement is degenerative arthritis (osteoarthritis) of the hip joint. This type of arthritis is generally seen with aging, congenital abnormality of the hip joint, or prior trauma to the hip joint. Other conditions leading to total hip replacement include bony fractures of the hip joint, and death (necrosis) of the hip bone. Hip bone necrosis can be caused by fracture of the hip, drugs (such as alcohol or corticosteroids), diseases (such assystemic lupus erythematosus), and conditions (such as kidney transplantation).
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The progressively intense, chronic pain — together with impairment of daily function including walking, climbing stairs and even rising from a sitting position — eventually become reasons to consider a total hip replacement. Because replaced hip joints can fail with time, whether and when to perform total hip replacement are not easy decisions, especially in younger patients. Replacement is generally considered after pain becomes so severe that it impedes normal function despite use of anti-inflammatory medications. A total hip joint replacement is an elective procedure, which means that it is an option selected among other alternatives. It is a decision which is made with an understanding of the potential risks and benefits. A thorough understanding of both the procedure and anticipated outcome is an important part of the decision-making process.
Risks:
The risks of total hip replacement include blood clots in the lower extremities that can travel to the lungs (pulmonary embolism). Severe cases of pulmonary embolism are rare, but can cause respiratory failure and shock. Other problems include difficulty with urination, local skin or joint infection, fracture of the bone during and after surgery, scarring and limitation of motion of the hip, and loosening of the prosthesis which eventually leads to prosthesis failure. Because total hip joint replacement requires anesthesia, the usual risks of anesthesia apply and include heart arrhythmias, liver toxicity, and pneumonia.
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Anatomy of the Knee
The knee is a hinged joint and is comprised of several structures.
Bones:
The femur (thigh bone - the largest bone in your body) extends from the hip to the knee joint. The tibia (shin bone - lower leg bone) connects to the knee joint also, and this area is covered by the patella (kneecap).
Cartilage:
Articular cartilage covers the bone ends of the femur and the tibia and assists it in allowing for a gliding motion in the joint.The menisci (lateral and medial meniscus) make up a “C” shaped cartilage that forms an actual cushion inside the joint, thus providing shock absorption.
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Ligaments
The bones are tethered, or bound together, by supportive ligaments (anterior cruciate, posterior cruciate). Surrounding muscles help move the joint, decrease stress to the joint, and provide additional support. Support and stability in the knee are provided by its four ligaments.
How the Knee Works
The fibrocartilaginous menisci of the knee are firmly attached to the tibia anteriorly and posteriorly, but are only loosely attached peripherally. During normal knee movement, they tend to move slightly inward or outward. Normal knee movement consists of a combination of movements (rotation, extension and flexion). These movements are controlled by the ligaments of the knee and by the menisci, which also aid in shock absorption.
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| Chondromalacia of the Patella
Chondromalacia of the patella is a painful outcome of some abnormal mechanical problem with patella (kneecap) tracking.
Diagnosis:
This diagnosis has come to be defined as any condition which creates a painful kneecap. In actuality, it is a diagnosis which can only be made when obvious articular cartilage changes are seen on MRI (magnetic resonance imaging) or through an arthroscope.
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Treatment
Treatment can include icing, bracing, anti-inflammatories and a rehabilitative exercise program which may include patellar taping for sports participation. Specific rehabilitative exercises to teach proper tracking of the patella are usually extremely helpful. These exercises will include straight leg raises which will strengthen the group of muscles known as the quadriceps.
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| Cruciate Ligaments of the Knee
Anterior Cruciate Ligament
The anterior cruciate ligament (ACL) in the knee prevents the tibia from sliding upon the femur by acting like a tether or rein. Injury to the ACL usually results from a twisting injury. Swelling, pain and instability in the knee generally point to an ACL tear. A physician will assess the knee for the severity of the sprain. X-rays are taken to rule out small associated fractures, and sometimes an MRI (magnetic resonance imaging) is necessary to confirm ligamentous tears and evaluate possible meniscal injury as well.
Treatment of partial ligament tears include a brief period of rest (24-72 hours), the use of anti-inflammatory medication, compression bandages, elevation and ice in an effort to reduce swelling.
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A gradual program of quadriceps and hamstring strengthening is emphasized as well. A dedicated physical rehabilitation program can be helpful for a return to full activity. Patients with complete tears are evaluated for potential recovery after nonsurgical treatment. Consideration is given to age, weight, activity level and severity of the injury.
If surgery is selected by both the physician and the patient, a ligament is reconstructed usually from the patient's own bone and tendon. Surgical intervention is generally quite successful if undertaken in conjunction with a dedicated physical therapy program. The reconstructed ligament itself takes up to a year to fully heal, but a patient can gradually return to weight bearing and athletic activity as he or she progresses through the rehabilitation program.
Posterior Cruciate Ligament
The posterior cruciate ligament also extends from the tibia to the femur, but in the back of the leg. It prevents the tibia from sliding backwards. Sprains of this area tend to occur in tandem with other major injuries to the knee. Posterior cruciate ligament (PCL) tears can be managed conservatively with a program of physical therapy emphasizing the hamstring and quadriceps muscle groups. With this injury, patients report a vague feeling of instability and this injury is generally confirmed with an MRI (magnetic resonance image).
If surgical management of this injury becomes an option, a lengthy and dedicated period of physical rehabilitation ensues, especially when other knee injuries are involved. Most patients respond well to treatment, however, and can return to an active life.
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| Meniscal Tears
The knee contains two menisci, fibrocartilaginous material which functions as stabilizers of the knee and provides a measure of shock absorption. Meniscal tears are the most common of all knee injuries, but the characteristics of each tear are variable.
Symptoms:
A patient with a meniscal injury will usually report a twisting event and sometimes the sensation of a “tear” or “pop” followed by severe pain on the medial (inside) portion of the knee.
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The patient will sometimes report that the knee “locks up.” It may be difficult to walk up or down stairs, or to squat. There may be some edema (swelling).
Diagnosis:
Diagnosis is made via plain films, clinical history, and confirmation is generally made through an arthroscopy, rarely by MRI (magnetic resonance image).
Treatment:
Some meniscal tears heal spontaneously after a period of rest, elevation and icing. Crutches are often used until the patient can walk without pain. Physical therapy would include range of motion and a quadriceps strengthening program to decrease edema and regain any muscle tone that may have been lost.
If the knee persistently “locks up” or the patient is unable to return to full activity, an MRI (magnetic resonance image) could be ordered to rule out a cyst or blockage. Arthroscopically, the meniscus can be repaired or partially removed with potentially excellent results. However, an exercise program would be the first choice in conservative management.
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| Meniscal Transplant
Meniscus
It is a c-shaped wedge of tough, rubbery cartilage in the knee about the size of a silver dollar. There are two menisci (plural of meniscus), one on each side of the knee joint. They act as shock absorbers, protecting the joint surface from daily wear and reducing friction between the thigh bone and shin bone. They also help stabilize the knee by controlling its rotation.
How is the Meniscus Injured?
Any sudden twisting of the knee can tear the cartilage, causing pain, swelling and a catching sensation. A “bucket-handle” tear, named for the shape of the tear, is a typical injury caused when the foot is planted in one direction and the knee twists in the other direction.
Treatment:
Since the turn of the century, the only treatment was to remove the entire cartilage wedge. Doctors now know that without the protection of the meniscus, the surface of the knee joint degenerates rapidly. The result is painful, disabling “wear and tear” arthritis (also called osteoarthritis) within 10 years for 70-90% of people.
The decision to repair or remove cartilage depends on the location and severity of the tear. If the meniscus cannot be repaired or has been previously removed, an innovative procedure called a meniscus transplant offers a positive solution.
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What is a Meniscus Transplant?
The newest frontier of medical science has made it possible to transplant donor cartilage into your knee. The transplant is approximately an hour-long, out-patient arthroscopic procedure or in-patient procedure. The patient will be in the hospital for approximately two days for the in-patient procedure. In the case of the arthroscopic procedure, a regional anesthesia is usually used and you will go home the same day. In most cases you will wear an immobilizer to keep your leg straight during 4 weeks of physical therapy. Most patients can return to normal activities, including recreational sports, within 12 weeks.
Why Should You Have a Meniscus Transplant?
It can dramatically slow the onset of painful, disabling arthritis and avoid or delay the need for knee replacement at a very early age. A transplant can allow you to continue working and enjoying your favorite sports or fitness activities.
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Who Should Have a Transplant
Anyone under the age of 50 who has had 50% or more of the meniscus removed is a candidate for a transplant. Also, anyone with a recent tear that cannot be repaired should consider a transplant. An x-ray and examination of your knee will determine if you can benefit from a meniscus transplant.
Where will I have incisions?
You will have only a 1" incision on the front of your knee, plus three “nicks” so small that a suture is not needed.
When can I return to work?
It varies with the activities your job requires, ranging from 3-4 days for desk jobs to 8 weeks for heavy labor.
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Patella Subluxation
A subluxed patella can be difficult to diagnose. Generally, the patella dislocates laterally.
Symptions:
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Edema (swelling) |
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Pain and the sensation of the knee “giving way” |
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Patients will generally report the initial injury occurred with a pivoting, twisting or cutting sports activity, such as football |
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Diagnosis
 A “skyline” or “sunrise” x-ray view can give a physician a good idea of displacement, if any. Clinically, a patient will present with medial knee pain, swelling and/or a description of the knee “giving way.” Sometimes, the patella may appear higher than normal when the knee is flexed (bent). This condition is known as patella alta. Treatment: Treatment is aimed at improving the extensor mechanism (muscles in the thigh) so that the knee (patella) can track in better alignment. Immobilization of an acutely subluxed patella will run a 4-6 week course concurrently with the use of cryotherapy (ice) to control edema and pain. Later, a course of therapy emphasizing strengthening of the quadriceps group will generally be prescribed. Strengthening of this area will greatly aid in decreasing future susceptibility to dislocations. If however, recurrent dislocation occurs, surgery may become an option. The extensor mechanism may need to be addressed through a variety of surgical procedures. The goal is to realign the patella and prevent lateral tracking problems from recurring. |
| Shin Splints
This term refers to a syndrome consisting of pain along the inner tibial shaft. The patient will describe a gradual increase in soreness and pain during walking.
Treatment:
Therapy and rehabilitation consist of rest, ice, a course of anti-inflammatory medications, heel cord and hamstring strengthening, and dorsiflexion of the foot. Shoes with proper flexibility and shock absorption should be employed for sports and athletic pursuits to prevent recurrence.
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Anterior Should Instibility
The shoulder can lose its normal retaining structures that prevent the abnormal subluxation of the humerus and the glenoid. The shoulder joint is surrounded by a capsule which is reinforced by a thickened area known as a ligament. Stretching or tearing of these reinforcement structures allow for abnormal slippage of the arm bone (humerus) and the shoulder cup (glenoid).
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Symptoms:
Patients will experience a feeling that the shoulder “is coming out of its joint” with activity. Sometimes, overhead activities such as pitching a baseball or serving in tennis will cause the arm to go numb. This is known as “dead arm syndrome.”
Diagnosis:
Evaluation usually involves a provocative physical exam and a specialized study such as MRI or CT arthrogram. An arthrogram is a test which involves injecting contrast material (dye) into a joint to better outline the internal structures. This test helps differentiate between normal anatomy and areas of injury.
Treatment:
This condition may respond to an exercise program but recurrent episodes and non-responsive joints may require surgical treatment.
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| Rotator Cuff Tear
The muscles and tendons of your rotator cuff help secure your shoulder and help move it as well. The rotator cuff can become inflamed or irritated (tendinitis) for a variety of reasons. If this irritation causes fraying or bruising, the joint will become weakened and painful. Overhead reaching may become difficult. Inflammation can also lead to a build up of calcium in the rotator cuff itself, which can inhibit movement and strength.
Severe tendinitis due to pinching (impingement) or degeneration or a traumatic fall can cause a partial or complete tear in the rotator cuff. This can result in shoulder pain, weakness and loss of normal movement.
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Diagnosis:
An MRI (magnetic resonance image) would be helpful in diagnosing a rotator cuff tear but a definitive clinical history and exam are of paramount importance.
Treatment:
Treatment consists of a course of anti-inflammatories, icing, and gentle stretching and strengthening exercises. Partial tears and chronic tendinitis may respond well to this conservative management, but occasionally, it is necessary to surgically repair a tear and debride tissue as necessary.
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| Arthritis of the Spine
Arthritis is a condition where the slippery joint surfaces of two bone ends are lost. This can be due to previous injury, age or other musculoskeletal issues. The spine is composed of 26 bones known as vertebrae. Between the vertebrae are discs. Each vertebra forms 3 joints with the vertebra above it and 3 joints with the vertebra below it. Any or all of these joints can lose their articular cartilage lining and develop arthritis.
Symptoms:
Symptoms of spinal arthritis include pain usually located anywhere in the back, flank or buttocks. The pain may radiate down an arm or leg.
Diagnosis:
Diagnosis can be made with a plain X-ray but may include an MRI (magnetic resonance image) or myelogram. A myelogram is an injection of contrast material (dye) into the cerebral spinal fluid (CSF) which occurs in the sac surrounding the spinal cord. These exams can tell us if spinal cords are under pressure or if nerve roots have become entrapped.
Treatment:
Treatment includes an exercise program to strengthen the back muscles and stabilize the spine. A medical doctor may try a course of anti-inflammatories or steroids may be injected into the spinal fluid to decrease pain and inflammation. Sometimes braces, abdominal binders or girdles are used in conjunction with the previously mentioned treatments. End-stage arthritic disease may require surgery to decompress the spinal cord and nerve roots and to stabilize the spine.
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Disc Herniation
The spine is comprised of 26 bones known as vertebrae. Between the vertebrae are discs which are made up of a surrounding capsule and a gelatinous substance. The disc functions as a spacer between vertebrae to allow for motion between vertebrae and to act as a shock absorber.
Disc herniation is a protrusion of the disc or its gelatinous substance beyond its normal confines and into the spinal canal. This condition can produce pressure on the spinal cord or nerve root and may result in pain, numbness or weakness in the extremities or along the spine.
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Diagnosis:
An MRI (magnetic resonance image) or myelogram are used for definitive diagnosis. A myelogram is an injection of contrast material (dye) into the cerebral spinal fluid (CSF) which occurs in the sac surrounding the spinal cord. This tells us if there is pressure on the spinal cord or nerve roots.
Treatment:
Treatment may include a weight loss program, “back school” (a regimented program of exercise to strengthen and stabilize the spine and proper biomechanics), a course of anti-inflammatory medication or a steroid injection into the epidural space (the epidural space is in the spine but just outside the spinal sac) to help decrease pain and inflammation. If conservative management fails, surgery to remove the disc becomes an option.
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| Lumbar Spine Strain
An exact diagnosis may be difficult to assess since muscular strain, ligamentous sprain and mild disc herniation may all present with similar symptoms. Symptoms will include muscular tenderness and weakness. Many factors can cause these symptoms but muscular or ligamentous injury are the usual culprits.
Treatment:
Regardless of the cause, initial treatment will be the same. A brief period of rest (usually 24-48 hours) and anti-inflammatory medication will be beneficial for the patient. This treatment can then be followed with a gradual return to weight-bearing activities.
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Many physicians will order a course of physical therapy for the patient which may include “back school.” “Back school” is a regimented program of exercise designed to strengthen and stabilize the muscles and ligamentous structures of the spine. The program also stresses proper body biomechanics which includes how to properly perform activities of daily living. This would include increasing the flexibility of the spine to better perform activities from tooth brushing to gas pumping to vacuuming. These classes and/or a course of physical therapy are ordered for the patient in an effort to reduce recurrence of injury.
Lifestyle changes may be employed as well to decrease predisposition to chronic low back pain. Smoking, which decreases overall circulation in the body should be eliminated. Obesity, poor body mechanics and wearing high heeled shoes are also indicators for low back pain. Whenever the body’s center of gravity is shifted forward, an added strain is placed upon the discs.
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| Nerve Root Irritation
It is uncommon for shoulder pain to be caused by nerve irritation. However, a suprascapular nerve can become entrapped and can cause weakness or an inability to flex, abduct and externally rotate the shoulder.
Compression of a nerve(s) in the cervical spine (neck) can cause a radiating pain in the arm or shoulder, making shoulder motion painful. Minor cases of nerve entrapment may respond to a course of physical therapy and anti-inflammatory medication. Patients generally respond well to moist heat on the affected area.
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If symptoms persist or worsen, a physician may order electromyography (EMG) or a magnetic resonance image (MRI) of the cervical spine. The EMG will help assess neuromuscular activity.
The nerve root is a peripheral extension of the central nervous system (CNS) that exits the spinal canal and terminates in the extremities. Its purpose is to transmit sensory information from the extremity to the brain and motor commands from the brain to the extremity.
Nerve root irritation is when some structure puts pressure upon the nerve root either in the form of a tumor, a fracture, arthritis, a congenital deformation, or herniated disc, a stenotic canal (narrowed spinal canal) or several other diagnoses.
Symptoms:
Symptoms include pain, numbness, tingling and weakness.
Diagnosis:
The diagnosis is made through a neurologic exam and confirmed through the use of an MRI (magnetic resonance image), EMG (electromyography), a discogram (when normal saline is injected into a disc to expand it and determine if this recreates pain) or CT myelogram. An EMG is an electrical test which determines the ability of a nerve to conduct an electrical charge. A myelogram is an injection of contrast material (dye) into the cerebral spinal fluid (CSF) which occurs in the sac surrounding the spinal cord.
Treatment:
Treatment may include a short period of rest (24-72 hours), anti-inflammatory medications, bracing and a gradual return to exercise. Steroid injections into the spinal canal may be helpful. Often, a back stabilization exercise program is extremely helpful to the patient.
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