Orthopedics

Tennis Elbow

Tennis elbow is a condition where the outer part of the elbow becomes sore and tender. The strain happens to the lateral forearm muscles near their origin on the lateral rounded protuberance (condyle) at the end of the humerous (forearm bone).

It is commonly associated with playing tennis and other racquet sports, though the injury can happen to almost anybody.

Tennis elbow is more prevalent in individuals over 40. Tennis elbow equally affects both sexes and although men have a marginally higher overall prevalence rate as compared women, this is not consistent within each age group, nor is it a statistically significant difference.

Symptoms include:

  • Recurring pain on the outside of the upper forearm just below the bend of the elbow; occasionally, pain radiates down the arm toward the wrist
  • Pain caused by lifting or bending the arm or grasping even light objects such as a coffee cup
  • Difficulty extending the full forearm fully because of inflamed muscles, tendons and ligaments
  • Pain that typically lasts for six to 12 weeks; the discomfort can continue for as little as three weeks or as long as several years

Ways to prevent tennis elbow include:

  • Decrease the amount of playing time if already injured or feel pain in outside part of elbow
  • Stay in overall good physical shape
  • strengthen the muscles of the forearm, upper arm, shoulder and upper back. Increased muscular strength will increase the stability of joints such as the elbow
  • Like other sports, use equipment appropriate towards your ability, body size and muscular strength

Treatment should start with rest, anti-inflammatory medications, and a stretching routine. If those fail to cure tennis elbow, surgery may be considered, although this form of treatment is rare (fewer than 3 percent of patients).

One procedure is for the tendon to be cut loose from the epicondyle, the rounded bump at the end of the bone, which eliminates stress on the tendon but renders the muscle useless. Another surgical technique involves removing roughened or granulated tissue in the tendon and repairing tears.

Spasticity

Spasticity is a condition in which certain muscles are continuously contracted. This contraction causes stiffness or tightness of the muscles and may interfere with movement, speech, and manner of walking.

Spasticity is usually caused by damage to the portion of the brain or spinal cord that controls voluntary movement.

Symptoms may include:

  • Hypertonicity – increased muscle tone
  • Clonus – a series of rapid muscle contractions
  • Exaggerated deep tendon reflexes
  • Muscle spasms
  • Scissoring – involuntary crossing of the legs
  • Fixed joints

The degree of spasticity varies from mild muscle stiffness to severe, painful, and uncontrollable muscle spasms. Spasticity can interfere with rehabilitation in patients with certain disorders, and often interferes with daily activities.

It may occur in association with:

The prognosis for those with spasticity depends on the severity of the spasticity and the associated disorder(s).

Treatment may include such medications as baclofen, diazepam, tizanidine or clonazepam. Physical therapy regimens may include muscle stretching and range of motion exercises to help prevent shrinkage or shortening of muscles and to reduce the severity of symptoms. Surgery may be recommended for tendon release or to sever the nerve-muscle pathway.

Shoulder

Shoulders are the work horses of the body. Some of the shoulder disorders that can occur include:

  • Athletic injuries
  • Overuse syndromes
  • Post-traumatic lesions
  • Degenerative lesions
  • Arthritis

Treatments vary by the type of injury and the condition of the patient.

Glenoid Labrum Tear

The glenoid, or socket joint of the shoulder, is surrounded by a fibrocartilaginous supporting structure called the labrum. Injuries to the tissue surrounding the shoulder socket can be caused by acute trauma or repetitive shoulder motions. Examples include falling on an outstretched arm, a direct blow to the shoulder, sudden pull or a violent overhead reach, such as occurs when trying to stop a fall or slide. Throwing athletes and weight lifters can experience tears due to repetitive shoulder motion.

Tears can be located either above (superior) or below (inferior) the middle of the glenoid socket. A SLAP lesion (superior labrum, anterior [front] to posterior [back]) is a tear of the rim above the middle of the socket that may also involve the biceps tendon.

Signs and symptoms of glenoid labrum tears include:

  • Pain, usually with overhead activities
  • Catching, locking, popping or grinding
  • Occasional night pain or pain with daily activities
  • A sense of instability in the shoulder
  • Decreased range of motion
  • Loss of strength

Treatment includes:

  • Rest
  • Cold therapy to reduce pain and inflammation
  • NSAID’s (non steroidal anti inflammatory drugs such as ibuprofen)
  • Rehabilitation program
  • Surgery to re-attach the labrum to the glenoid

Following surgery the shoulder will usually be kept in a sling for 3 or 4 weeks. More sports specific training can be done after 6 weeks, although full fitness may take 3 or 4 months.

Rotator Cuff Tear

Although there are many reasons for shoulder pain, a common problem for people over 40 years of age is a rotator cuff tear.

The rotator cuff is comprised of the muscles and tendons that surround the top of the upper arm bone – the humerus — and hold it in the shoulder joint. A sudden tear may result from a single traumatic event or develop gradually because of repetitive overhead activities. A partial tear may cause pain when the arm is lifted in a certain arc away from the body (painful arc syndrome) and a complete tear may limit the aility to raise the arm.

Signs and symptoms of rotator cuff tears are:

  • Recurrent, constant pain, particularly with overhead activities.
  • Pain at night that prevents you from sleeping on the affected side.
  • Muscle weakness, especially when attempting to lift the arm.
  • Catching and grating or cracking sounds when the arm is moved.
  • Limited motion.
  • Usually occurs in the dominant arm, which is the right shoulder for right-handed people; left shoulder for left-handed people.
  • May be triggered by a specific incident.

Most rotator cuff tears can be treated without surgery. Non-operative rotator cuff treatments may include:

  • Physical therapy
  • Anti-inflammatory pain medications
  • Cortisone injections

The goal of treatment is to reduce inflammation and strengthen the uninjured muscles around the shoulder to compensate for the torn muscles.

In the minority of patients where non-surgical treaments are not effective, surgery may be recommended. Surgery is performed to repair the torn tendons.

Shoulder Fracture

Shoulder blade fractures represent 1 percent of all broken bones. High energy blunt trauma, such as a motorcycle or car crash or falling from a significant height can fracture the shoulder blade.

Signs and symptoms for shoulder fractures include:

  • Extreme pain when you move the arm
  • Swelling around the back of the shoulder
  • Skin abrasions
  • Redness and bruising around the area
  • Bones may appear out of position

Both diagnosis and severity of a shoulder fracture can be confirmed by X-rays.

Nonsurgical treatment with a simple sling works for most fractures of the scapula or shoulder blade. The immobilization device holds your shoulder in place while the bone heals.

If you have a fracture where the bone has moved out of place significantly, or where a fracture in the neck of the scapula results in severe deformity of the bone, you may need further evaluation. In some cases, you may need surgery in which the doctor uses plates and screws to hold the bone together.

Repetitive Motion Disorders

Repetitive motion disorders (RMDs) are a family of muscular conditions that result from repeated motions performed in the course of normal work or daily activities.

RMDs include:

RMDs are caused by too many uninterrupted repetitions of an activity or motion, unnatural or awkward motions such as twisting the arm or wrist, overexertion, incorrect posture, or muscle fatigue.

Generally, RMDs affect individuals who perform repetitive tasks such as assembly line work, meatpacking, sewing, playing musical instruments, and computer work. The disorders may also affect individuals who engage in activities such as carpentry, gardening, and tennis.

RMDs occur most commonly in the hands, wrists, elbows, and shoulders, but can also happen in the neck, back, hips, knees, feet, legs, and ankles.

The disorders are characterized by:

  • Pain
  • Tingling
  • Numbness
  • Visible swelling or redness of the affected area
  • The loss of flexibility and strength

For some individuals, there may be no visible sign of injury, although they may find it hard to perform easy tasks Over time.

RMDs can cause temporary or permanent damage to the soft tissues in the body — such as the muscles, nerves, tendons, and ligaments – and compression of nerves or tissue.

Most individuals with RMDs recover completely and can avoid re-injury by changing the way they perform repetitive movements, the frequency with which they perform them, and the amount of time they rest between movements. Without treatment, RMDs may result in permanent injury and complete loss of function in the affected area.

Treatment for RMDs usually includes reducing or stopping the motions that cause symptoms. Options include taking breaks to give the affected area time to rest, and adopting stretching and relaxation exercises. Applying ice to the affected area and using medications such as pain relievers, cortisone, and anti-inflammatory drugs can reduce pain and swelling. Splints may be able to relieve pressure on the muscles and nerves. Physical therapy may relieve the soreness and pain in the muscles and joints. In rare cases, surgery may be required to relieve symptoms and prevent permanent damage. Some employers have developed ergonomic programs to help workers adjust their pace of work and arrange office equipment to minimize problems.

Post-Polio Syndrome

Post-polio syndrome (PPS) is a condition that affects polio survivors anywhere from 10 to 40 years after recovery from an initial paralytic attack of the poliomyelitis virus. PPS is characterized by a further weakening of muscles that were previously affected by the polio infection.

Symptoms include:

  • Fatigue
  • Slowly progressive muscle weakness
  • At times, a decrease in muscle size (muscular atrophy)
  • Joint pain
  • Increasing skeletal deformities such as scoliosis

Some patients experience only minor symptoms, while others develop spinal muscular atrophy, and very rarely, what appears to be, but is not, a form of amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s disease. PPS is rarely life-threatening.

PPS is a very slowly progressing condition marked by long periods of stability. The severity of PPS depends on the degree of the residual weakness and disability an individual has after the original polio attack. People who had only minimal symptoms from the original attack and subsequently develop PPS will most likely experience only mild PPS symptoms. People originally hit hard by the polio virus, who were left with severe residual weakness, may develop a more severe case of PPS with a greater loss of muscle function, difficulty in swallowing, and more periods of fatigue.

Presently, no prevention has been found. Doctors recommend that polio survivors follow standard healthy lifestyle practices:

  • Consuming a well-balanced diet
  • Exercising in moderation
  • Visiting a doctor regularly

There has been much debate about whether to encourage or discourage exercise for polio survivors or individuals who already have PPS. A commonsense approach, in which people use individual tolerance as their limit, is currently recommended.

Polymyalgia Rheumatica and Giant Cell Arteritis

Polymyalgia rheumatica is a rheumatic disorder associated with moderate-to-severe musculoskeletal pain and stiffness in the neck, shoulder, and hip area.

Giant cell arteritis is a disorder that results in inflammation of arteries of the scalp, neck, and arms. This inflammation causes the arteries to narrow, impeding adequate blood flow.

Polymyalgia rheumatica and giant cell arteritis frequently occur together, although it is unclear how or why. Some people with polymyalgia rheumatica also develop giant cell arteritis either simultaneously, or after the musculoskeletal symptoms have disappeared. Other people with giant cell arteritis also have polymyalgia rheumatica at some time while the arteries are inflamed. It is important that doctors look for symptoms of the arteritis in anyone diagnosed with polymyalgia rheumatica.

Polymyalgia rheumatica and giant cell arteritis are both quite common. In North America, it is estimated that 700 per 100,000 people in the general population over 50 years of age develop polymyalgia rheumatica. An estimated 200 per 100,000 people over 50 years of age develop giant cell arteritis.

Caucasian women over the age of 50 have the highest risk of developing polymyalgia rheumatica and giant cell arteritis. Both conditions almost exclusively affect people over the age of 50. The incidence of both peaks between 70 and 80 years of age. Although women are more likely than men to develop the conditions, research suggests that men with giant cell arteritis are more likely to suffer potentially blinding eye involvement.

Most people with polymyalgia rheumatica and giant cell arteritis lead productive, active lives. The treatment of choice for both polymyalgia rheumatica and giant cell arteritis is corticosteroid medication, usually prednisone. The duration of drug treatment differs by patient. Once treatment is discontinued, polymyalgia may recur; but symptoms respond rapidly to prednisone. When properly treated, giant cell arteritis rarely recurs.

Whether taken on a long-term basis for polymyalgia rheumatica or for a shorter period for giant cell arteritis, prednisone carries a risk of side effects. Although long-term use and/or higher doses carry the greatest risk, people taking the drug at any dose or for any length of time should be aware of the potential side effects, which include:

  • Fluid retention and weight gain
  • Rounding of the face
  • Delayed wound healing
  • Bruising easily
  • Diabetes
  • Myopathy (muscle wasting)
  • Glaucoma
  • Increased blood pressure
  • Decreased calcium absorption in the bones, which can lead to osteoporosis
  • Irritation of the stomach
  • Increase in infections

People taking corticosteroids may have some side effects or none at all. Anyone who experiences side effects should report them to his or her doctor. When the medication is stopped, the side effects disappear. Because prednisone and other corticosteroid drugs reduce the body’s natural production of corticosteroid hormones, which are necessary for the body to function properly, it is important not to stop taking the medication unless instructed by a doctor to do so. The patient and doctor must work together to gradually reduce the medication.

Polymyalgia Rheumatica

Polymyalgia rheumatica is a rheumatic disorder associated with moderate-to-severe musculoskeletal pain and stiffness in the neck, shoulder, and hip area. Stiffness is most noticeable in the morning or after a period of inactivity, and typically lasts longer than 30 minutes.

This disorder may develop rapidly; in some people it comes on literally overnight. But for most people, polymyalgia rheumatica develops more gradually.

The cause of polymyalgia rheumatica is not known. But it is associated with immune system problems, genetic factors, and an event, such as an infection, that triggers symptoms. The fact that polymyalgia rheumatica is rare in people under the age of 50 and becomes more common as age increases, suggests that it may be linked to the aging process.

In addition to the musculoskeletal stiffness mentioned earlier, people with polymyalgia rheumatica also may have:

  • Flu-like symptoms
  • Fever
  • Weakness
  • Weight loss

Polymyalgia rheumatica responds to a low daily dose of prednisone that is increased as needed until symptoms disappear. At this point, the doctor may gradually reduce the dosage to determine the lowest amount needed to alleviate symptoms. Most patients can discontinue medication after 6 months to 2 years. If symptoms recur, prednisone treatment is required again.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil, Motrin), also may be used to treat polymyalgia rheumatica. The medication must be taken daily, and long-term use may cause stomach irritation. For most patients, NSAIDs alone are not enough to relieve symptoms.

Even without treatment, polymyalgia rheumatica usually disappears in 1 to several years. With treatment, however, symptoms disappear quickly, usually in 24 to 48 hours. If prednisone doesn’t bring improvement, the doctor is likely to consider other possible diagnoses.

Giant Cell Arteritis

Giant cell arteritis, also known as temporal arteritis and cranial arteritis, is a disorder that results in inflammation of arteries of the scalp (most apparent in the temporal arteries, which are located on the temples on each side of the head), neck, and arms. This inflammation causes the arteries to narrow, impeding adequate blood flow.

Early symptoms of giant cell arteritis may resemble flu symptoms such as fatigue, loss of appetite, and fever. Symptoms specifically related to the inflamed arteries of the head include:

  • Headaches
  • Pain and tenderness over the temples
  • Double vision or visual loss
  • Dizziness
  • Problems with coordination and balance
  • Pain may affect the jaw and tongue, especially when eating
  • Opening the mouth wide may become difficult
  • In rare cases, giant cell arteritis causes ulceration of the scalp

Giant cell arteritis is treated with high doses of prednisone. If not treated promptly, the condition carries a small but definite risk of blindness or stroke, so prednisone should be started as soon as possible, perhaps even before confirming the diagnosis with a temporal artery biopsy.

As with polymyalgia rheumatica, the symptoms of giant cell arteritis quickly disappear with treatment; however, high doses of prednisone are typically maintained for 1 month. Once symptoms disappear and the sed rate is normal, there is much less risk of blindness. At that point, the doctor can begin to gradually reduce the prednisone dose.

Plantar Fasciitis

Plantar fasciitis is the most common cause of heel pain. The plantar fascia is the ligament that connects your heel bone to your toes. It supports the arch of your foot. If you strain your plantar fascia, it gets weak, swollen, and inflamed. Then your heel or the bottom of your foot hurts when you stand or walk.

Plantar fasciitis is common in middle-aged people. It also occurs in younger people who are on their feet a lot, like athletes or soldiers. It can happen in one foot or both feet.

Plantar fasciitis is caused by straining the ligament that supports your arch. Repeated strain can cause tiny tears in the ligament. These can lead to pain and swelling. This is more likely to happen if:

  • Your feet roll inward too much when you walk (excessive pronation).
  • You have high arches or flat feet.
  • You walk, stand, or run for long periods of time, especially on hard surfaces.
  • You are overweight.
  • You wear shoes that don’t fit well or are worn out.
  • You have tight Achilles tendons or calf muscles.

Most people with plantar fasciitis have pain when they take their first steps after they get out of bed or sit for a long time. You may have less stiffness and pain after you take a few steps, but your foot may hurt more as the day goes on. It may hurt the most when you climb stairs or after you stand for a long time.

Plantar fasciitis most often occurs because of injuries that have happened over time. With treatment, you will have less pain within a few weeks. In some cases it may take a few months to a year for the pain to go away completely.

No single treatment works best for everyone with plantar fasciitis. But there are many things you can try to help your foot get better:

  • Give your feet a rest. Cut back on activities that make your foot hurt. Try not to walk or run on hard surfaces.
  • To reduce pain and swelling, try putting ice on your heel.
  • Take an over-the-counter pain reliever like ibuprofen (such as Advil or Motrin), naproxen (such as Aleve), or ASA.
  • Do calf stretches and towel stretches several times a day, especially when you first get up in the morning.
  • Get a new pair of shoes. Pick shoes with good arch support and a cushioned sole.
  • Try heel cups or shoe inserts (orthotics). Use them in both shoes, even if only one foot hurts.

If these treatments do not help, your doctor may give you splints that you wear at night, shots of steroid medicine in your heel, or other treatments. Surgery is only suggested for people who still have pain after trying other treatments for 6 to 12 months.

PCL Tear

The posterior cruciate ligament (PCL) is about two inches long and connects the femur to the tibia at the back of the knee. It limits the backward or posterior motion of the tibia (shinbone). Twisting or overextending the knee can cause the PCL to tear, leaving the knee unstable and potentially unable to support a person’s full body weight.

The PCL is the strongest ligament in the knee, and tears often are associated with traumatic injuries rather than sports injuries. PCL tears can happen when the knee is violently forced backward or when the front of the shin is hit hard, for example when the knee strikes the dashboard during a car accident.

Since PCL tears usually result from a violent blow to the knee, they are often accompanied by injuries to other knee ligaments. Although rare, PCL tears can occur when playing rugby, football or other contact sports.

Symptoms of a PCL tear can vary; the most obvious include pain, swelling and a feeling of unsteadiness in the knee.

Initial treatment consists of the use of crutches, ice, and elevation.

Isolated PCL tears are usually treated with rehabilitation rather than surgery. However, your doctor may recommend surgery if you have other ligament injuries along with the tear. The decision to have surgery is a personal choice. However, factors such as age, physical condition and athletic goals will help you and your doctor determine the best treatment for your situation.

The surgical procedure usually will reconstruct your PCL using a graft from another part of your body (called an autograft) or a cadaver (called an allograft). The graft serves as a scaffold for the PCL reconstruction, and the type of graft used is based on patient and surgeon preference.

People who are not very active may choose an exercise-strengthening program instead of surgery, since the injury is not likely to interfere with their daily activities. It can take up to six months to complete this type of rehabilitation program.

Patellofemoral Pain Syndrome

The kneecap or patella is a small, triangular bone in the front of your knee that moves with the knee as it flexes. It glides up and down along a track at the end of the thighbone (femur) and gives the front thigh muscles (quadriceps) extra leverage for straightening the leg. The patella also protects the other bones in the knee against collisions and falls.

Patellofemoral pain syndrome occurs when the patella cartilage becomes overloaded due to overuse (often caused by high-impact activities) or as a result of poor alignment. High-impact sports — such as football, basketball, soccer, tennis and running — can aggravate existing abnormal kneecap alignment. In addition, running on uneven surfaces, like hills or trails, or playing on multiple surfaces (such as going from a grass to a hard court in tennis) also may increase the likelihood of patellofemoral pain. It is the most frequently encountered diagnosis in sports medicine clinics.

The most common symptom of patellofemoral pain syndrome is a dull ache underneath the kneecap while walking down stairs, squatting or getting up after sitting for long periods of time. In addition, your knee may catch when bending, and you may experience a painful grating or creaking sensation.

Although many active people notice symptoms when starting new activities or increasing their level of intensity, especially with respect to high-impact sports, non-active people can suffer patellofemoral pain during routine daily activities as well.

Treatment consists of:

  • Quadriceps strengthening
  • Stretching
  • Rest
  • Ice and anti-inflammatory drugs
  • Taping and knee brace (used in conjunction with physical therapy)
  • Footwear, arch supports, and custom orthotics

Pallister-Hall Syndrome

Pallister-Hall syndrome is a genetic disorder that affects the development of many parts of the body.

Mutations in the GLI3 gene cause Pallister-Hall syndrome. The GLI3 gene provides instructions for making a protein that controls gene expression, which is a process that regulates whether genes are turned on or off in particular cells. By interacting with certain genes at specific times during development, the GLI3 protein plays a role in the normal shaping of many organs and tissues before birth.

This condition is very rare; its prevalence is unknown. It is inherited in an autosomal dominant pattern, which means one copy of the altered gene in each cell is sufficient to cause the disorder. In some cases, an affected person inherits a mutation in the GLI3 gene from one affected parent. Other cases result from new mutations in the gene and occur in people with no history of the disorder in their family.

Most people with this condition have:

  • Extra fingers and/or toes (polydactyly)
  • The skin between some fingers or toes may be fused (cutaneous syndactyly)
  • An abnormal growth in the brain called a hypothalamic hamartoma
  • A malformation of the airway called a bifid epiglottis
  • An obstruction of the anal opening (imperforate anus)
  • Kidney abnormalities

Although the signs and symptoms of this disorder vary from mild to severe, only a small percentage of affected people have serious complications.

In many cases, these growths do not cause any medical problems. However, some hypothalamic hamartomas lead to seizures or hormone abnormalities that can be life-threatening in infancy. The most common types of seizures that occur are known as Gelastic Epilepsy. Seizures may begin at any age but usually before three or four years of age. The seizures usually start with laughter that is often described as being ‘hollow’ or ’empty’ and not very pleasant. The laughter occurs suddenly, comes on for no obvious reason and is usually completely out of place.

Treatment of individuals with Pallister-Hall syndrome depends on their individual manifestations. Management of epiglottic abnormalities depends on the type of abnormality and extent of respiratory compromise. Treatment for endocrine abnormalities, especially for cortisol deficiency, is urgent. Repair of polydactyly can be undertaken on an elective basis and anal atresia or stenosis treated in the standard manner. Hypothalamic hamartomas should not be removed or biopsied because of the risk of surgical complications and need for hormone supplements during the individual’s remaining life. Gelastic seizures are not responsive to therapy so they are treated symptomatically.