Introduction

Arthroscopic Surgery is a procedure that allows surgeons to see, diagnose, and treat problems inside a joint.  The procedure, also called an Arthroscopy, requires only small incisions and is guided by a miniature viewing instrument or scope.  Before arthroscopy existed, surgeons made large incisions that affected the surrounding joint structures and tissues.  They had to open the joint to view it and perform surgery.  The traditional surgery method carries a higher risk of infection and requires a longer time for recovery.  In contrast, arthroscopy is less invasive.  It has a decreased risk of infection and shorter recovery period.  Today, arthroscopic surgery is one of the most common orthopedic procedures.

Treatment

Arthroscopic Surgery uses an arthroscope, which is a very small surgical instrument; about the size of a pencil.  An arthroscope contains a lens and lighting system that allows a surgeon to view inside a joint. The surgeon only needs to make small incisions and the joint does not have to be opened up fully. The arthroscope can be attached to a miniature camera.  The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.   
Initially, the arthroscope was designed as a diagnostic tool for planning traditional open joint surgeries.  A surgeon uses an arthroscope to diagnose joint conditions when physical examinations or imaging scans are not conclusive.  The diagnostic accuracy of arthroscopy is highly precise.  As the technology developed, special surgical instruments were created to use with the arthroscope. Now, it can be used to treat conditions as well.  Like the arthroscope, the thin surgical instruments are inserted into the joint through small incisions.  Some injuries or problems are treated with a combination of arthroscopic and open surgery.  
 
Conditions Treated with Arthroscopy
 
Although nearly all joints can be viewed with an arthroscope, it is used most frequently to treat six joints.  These include the knee, shoulder, elbow, ankle, hip and wrist.  Arthroscopy most commonly treats diseases and injuries that damage the bones, cartilage, ligaments, tendons, and muscles that make up a joint.
Bones are the hardest tissues in our body.  They support our body structure and meet to form joints.  Cartilage covers the ends of many of our bones. The cartilage forms a smooth surface and allows the bones to glide easily during motion.  Disease and injury can compromise the cartilage and joint structure and disrupt their functions.  
 
A condition called Chondromalacia can cause the cartilage to soften and deteriorate because of injury, disease, or “wear and tear.”  The curved cartilage in the knee joint, called a meniscus, is especially vulnerable to tears during injury.  An arthroscopic surgery can treat these conditions by shaving and smoothing out the cartilage.  It can also remove abnormal growths from bones, such as calcium deposits and bone spurs. 

Tendons are strong fibers that attach our muscles to our bones.  They are tissues that do not stretch easily and are susceptible to tears under repeated or traumatic stress.  Ligaments are strong tissues that connect our bones together and provide structural support.  The ligaments are lined with Synovial Membrane called Synovium.  The Synovium secretes a thick liquid called Synovial Fluid.  The Synovial Fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions.  Trauma and “wear and tear” from overuse can cause injury and inflammation to our tendons, ligaments, and Synovium.  
 
Tendons in the shoulder and ligaments in the knee are frequently torn or impinged from trauma and overuse.  An arthroscopy can repair tendons.  Many ligaments and tendons can be repaired arthroscopically.  Synovitis, a condition caused by an inflamed lining of a joint, can develop in the knee, shoulder, elbow, wrist, or ankle.  Arthroscopy can treat synovitis by removing scar tissue or the inflamed synovium.  A synovial biopsy, a tissue sample for examination, can be done via arthroscopy.
 
What to Expect
 
Arthroscopic surgery is usually performed as an outpatient procedure.  In some cases, an overnight stay in the hospital may be needed.  You may be sedated for the surgery or receive a local or regional anesthetic to numb the area, depending on the joint or suspected problem.  Before the surgery, your surgeon will elevate your limb and apply a tourniquet, an inflatable band.  This will reduce the blood flow to your joint during the procedure. 
 
Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your joint.  Your surgeon will fill the joint space with a sterile saline (salt-water) solution.  Expansion of the space allows your surgeon to have a better view of your joint structures.  Your surgeon will insert the arthroscope and manipulate it to see your joint from different angles.  If you are having another surgical procedure, your surgeon may make additional small incisions and use other slender surgical instruments.  When your procedures are completed, your surgeon may inject your joint with medication to reduce pain and inflammation.  Because the incisions are so small, they will require just a few stitches 
 
Your recovery time will depend on the extent of your condition and the amount of surgery that you had.  Your surgeon will let you know what to expect.  Your surgeon may restrict your activity for a short period of time following your surgery.  It is common for people to return to work or school within a few days.  In some cases, rehabilitation is recommended to mobilize and strengthen the joint.  It usually takes a joint several weeks to fully recover.
 
Benefits of Arthroscopy 
 
An arthroscopy can be a short procedure.  In some cases, it may only take minutes for the actual surgery.  Because it is often a shorter procedure, a smaller amount of anesthesia is required and individuals need to be sedated for shorter amounts of time than with open joint surgery.  Most people have the procedure as an outpatient and return to their homes in just a few hours.
 
Overall, an arthroscopy requires a shorter length of time for recovery than open joint surgery.  It also has a reduced risk of infection and causes less pain because only small incisions are used and less surrounding tissue is affected or exposed.

Introduction

The Achilles tendon is the most powerful tendon in the human body.  Tendons are strong tissues that connect muscles to bone.  The Achilles tendon is located in the lower back part of the leg and works with the calf muscles to provide forceful foot movements.  Achilles tendon ruptures most commonly occur as a result of sports injuries from activities such as basketball, football, or tennis.  They can also result from a condition called Achilles tendonitis.  Individuals with Achilles tendonitis have weakened and inflamed tendons that are susceptible to injury.

Anatomy

The Achilles tendon is a large, strong fibrous cord that connects the calf muscles in the back of the leg to the back of the heel bone (calcaneus).  The Achilles tendon and the calf muscles work together to allow individuals to point the foot downward and to raise the heel upward.  People rely on it virtually every time they move their foot.  This motion enables individuals to walk, jump, stand on their toes, and climb stairs.  Individuals with Achilles tendon ruptures will most often not be able to perform such movements.

Causes

Achilles tendon ruptures most commonly occur in men between the ages of 30 and 50 years old that participate in sports.  Sports such as basketball, football, and tennis require quick forward and backward leg movements, jumping, and cutting that can create an imbalance of pressure on the leg and foot.  The Achilles tendon can rupture when the flexed foot sustains a sudden strong force and the calf muscles powerfully shorten.  Achilles tendon rupture can also result from tendons weakened over time by Achilles tendonitis (chronic inflammation of the tendon).

Symptoms

A loud “pop” may be heard when the Achilles tendon ruptures.  Most individuals feel a sudden painful “snap” in the back of the calf or lower leg followed by sharp severe pain.  Swelling and skin discoloration in the back of the calf will often develop because of bleeding beneath the skin.  Individuals are unable to point their feet downward or raise their heels upward making it difficult to walk, jump, stand on their toes, and climb stairs.

Diagnosis

In order to diagnose an Achilles tendon rupture, a physician will perform an examination and review the individual’s medical history.  The Thompson Test is the most reliable physical examination to confirm a suspected Achilles tendon rupture.  The test is simple to perform.  The individual lies face down with the leg straight.  The physician squeezes the calf muscles in the leg.  If the foot does not point, the Achilles tendon may have ruptured.  The foot will not be able to point because the tendon connecting the calf muscles at the heel is torn.  Some physicians may order medical imaging tests, such as ultrasound or Magnetic Resonance Imaging (MRI), to determine the location and type of tendon tear.  An ultrasound uses sound waves to create an image when a device is gently placed on the skin.  An MRI provides a very detailed view of body structures.  The MRI equipment focuses on the leg area while the individual remains very still.  In some cases, x-rays are ordered to assess if the leg or heel bone was injured when the Achilles tendon ruptured. 

Treatment

Each case of Achilles tendon rupture must be evaluated on an individual basis.  It is important for the individual and physician to discuss and determine which treatment options are most appropriate.  Treatment for Achilles tendon ruptures can be surgical or nonsurgical.

Surgery is not recommended for inactive individuals or those who are at high risk for complications or cannot tolerate surgery.  Treatment for these individuals includes approximately six weeks of casting to allow the tendons to heal, followed by physical therapy.  Physical Therapists focus on improving physical functioning by addressing muscle strength, flexibility, endurance, balance, and coordination.  This method can be effective, and it avoids the risks, such as infection, associated with surgery

Surgery

For individuals with active lifestyles and who want to return to strenuous recreational activities, physicians recommend surgery to reattach the torn Achilles tendon.  Surgery is generally very effective and the risk of complication is typically low.  The surgery will require anesthesia, but can also be performed on an out-patient basis.  The surgeon makes a three to four inch opening behind the ankle and reattaches the tendon ends to each other or to the bone.  The foot is placed in a pointed position in a splint or short leg cast.  The splint or cast is worn for four to six weeks.  The individual participates in physical therapy when the healing is complete.

Recovery

Individuals with surgical and non-surgical repair have good to excellent rates of returning to full activity levels with proper treatment and rehabilitation.  The length of time for healing is highly variable.  Generally, individuals with surgical repair can return to walking and swimming at six weeks, and gradually return to sports several months from the surgery.  They have a lower risk of repeated tendon rupture and a better chance of regaining full strength in the leg.  Individuals with non-surgical repair will often participate in rehabilitation for a longer period of time.  They have a higher risk of repeated tendon rupture and loss of strength.

Introduction

The anterior cruciate ligament (ACL)is one of the most commonly injured ligaments in the knee. Ligaments are strong non-elastic fibers that connect our bones together. The ACL crosses inside of the knee, connecting the thighbone to the leg. It provides stability to the knee joint.

ACL tears most commonly occur in very active people or athletes. The ACL can tear when people abruptly slow down from running, land from a jump, or change directions rapidly.  These types of actions are frequently performed during sports, such as football, basketball, skiing, and soccer. Athletes are especially at risk for ACL tears, although they may occur in active workers and the general population as well.

The ACL can tear completely or partially. It is unable to repair itself. When the ACL is injured, it is common to see other surrounding knee structures damaged as well. Some cases of ACL tears are treated with non-surgical methods. However, there are several surgical options that successfully restore knee strength and stability.

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Anatomy

The knee is structurally complex. Our knee is composed of three bones. The femur, or thighbone, sits on top of the tibia, the larger leg bone. The patella, or kneecap, glides in a groove on the end of the femur. 
 
Large muscle groups in the thigh give the knee strength and stability. The quadriceps muscles are a large group of muscles on the front of our thigh that straighten and rotate the leg. The hamstring muscles are located on the back of the thigh and bend or flex the knee.
 
Four ligaments connect our knee bones together. The ligaments are strong tissues that provide stability and allow motion. The ligaments enable our knee to have the flexibility to move in various directions while maintaining balance. The medial collateral ligament is located on the inner side of our knee. The lateral collateral ligament is at the outer side of our knee. These two ligaments help the joint to resist side to side stress and maintain positioning.
 
The anterior cruciate ligament and the posterior cruciate ligament cross inside of the knee joint. These two ligaments help to keep the joint aligned. They counteract excessive forward and backward forces and prohibit displacement of the bones. They also produce and control rotation of the tibia. We rotate our tibia when we turn our leg outward to push off the ground with our foot. We use this motion to push off from the side when skate, run, or move our body to get into a car.

Two cartilage disks, called menisci, are located on the end of the tibia. The cartilage forms a smooth surface and allows our bones to glide easily during motion. The menisci also act as shock absorbers when we walk or run. 
 
A smooth tissue capsule covers the bones in our knee joint. A thin synovial membrane lines the capsule. The synovium secretes a thick liquid called synovial fluid. The synovial fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions.

Proprioceptive nerve fibers are contained in the ligaments and joint capsule. The proprioceptive nerve endings send signals about body movements and positioning.  For instance, the proprioceptors in the knee send signals to let us know how far to bend our joint in order to place our foot  for a step. They plan and coordinate our leg movements whenever we move.

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Causes

The ACL can tear during strong twisting motions of the knee. The ACL can also tear if the knee is hyperextended or bent backwards. People frequently tear the ACL while pivoting, landing awkwardly from a jump, changing directions suddenly, or abruptly slowing down from running. ACL tears occur most frequently in young athletes.  Football, basketball, skiing, and soccer are sports associated with the highest injury rates. 

Researchers show that female athletes have a higher rate of ACL injury than males in certain sports. They suspect the greater angles in the female hip and leg alignment may make the knee more vulnerable to force. Additionally, female hormones can relax ligaments and make them less stable, making some women more susceptible to knee injury.

It is common for additional injuries to result when an ACL tear occurs. Surrounding structures, such as the meniscus, cartilage, and ligaments can be injured as well.  Some people may also experience bruised or broken bones. The ACL can tear during strong twisting motions of the knee. The ACL can also tear if the knee hyperextends or bends backwards. People frequently tear the ACL while pivoting, landing awkwardly from a jump, changing directions suddenly, or abruptly slowing down from running. 

ACL tears occur most frequently in young athletes. Football, basketball, skiing, and soccer are sports associated with the highest injury rates. 

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Symptoms

People usually experience pain, swelling, and knee instability immediately after the ACL tears. Your knee may buckle or give out on you. You may not be able to fully straighten your knee. You may have difficulty moving your knee and walking. Typically, within a few hours the swelling in the knee increases dramatically.

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Diagnosis

If you suspect you have torn your ACL, you should go to your doctor or an emergency room right away. A doctor can evaluate your knee by gathering your medical history, performing a physical examination, and viewing medical images. Your doctor will ask you about your symptoms and what happened if you were injured. Your doctor will examine your knee and your leg alignment. You will be asked to perform simple movements to help your doctor assess your muscle strength, joint motion, and stability.

Doctors typically perform the Lachman Test to determine if the ACL is intact. For this test, you will lie on your back and slightly bend your knees. Your doctor will place one hand on your thigh and attempt to pull your leg forward with the other hand. Your doctor will test both of your legs to compare the results. If you can move your leg three to five millimeters, the test is positive. 

The Pivot Shift Test is another test to determine if the ACL is functioning. For this test, you will straighten your leg. Your doctor will hold your leg while turning it and moving it toward your body. If your leg moves in and out of position, the test is positive for an ACL tear.

Your physician will order X-rays to see the condition of the bones in your knee and to identify fractures. Sometimes a fracture or soft tissue injury does not show up on an X-ray. In this case, your doctor may order a magnetic resonance imaging (MRI) scan. An MRI scan will provide a very detailed view of your knee structure. Like the X-ray, the MRI does not hurt and you need to remain very still while the images are taken.

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Treatment

Initially following an injury, your knee will be treated with rest, ice, compression, and elevation. You should rest your knee by not placing weight on it. You may use crutches to help you walk. Applying ice packs to your knee can help reduce pain and swelling.  You should apply ice immediately after injuring your knee. Your doctor will provide you with a continued icing schedule. Your doctor may provide over-the-counter or prescription pain medication. In some cases, a knee brace may be recommended to immobilize and support the knee. A knee immobilizer is used for only a short period of time. Elevating your knee at a level above your heart helps to reduce swelling.

Treatment for ACL tears is very individualized. Many factors need to be considered, such as your activity level, severity of injury, and degree of knee instability. Treatments may include physical therapy, surgery, or a combination of both. The most likely candidates for non-surgical treatments have partial ACL tears without knee instability, complete tears without knee instability, sedentary lifestyles or are willing to give up high-demand sports, or are children whose knees are still developing. 

Physical therapy and rehabilitation can help restore knee functioning for some individuals. Your physical therapist will help you strengthen your knee. Special emphasis is placed on exercising the quadriceps muscles on the front of the thigh and the hamstring muscles on the back of the thigh. Eventually, you will learn exercises to improve your balance and coordination. You may need to wear a knee brace during activities. Your therapists will educate you on how to prevent further injury.

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Surgery

Surgical treatment is most frequently recommended for individuals with ACL tears accompanied with other injuries. The most likely candidates for surgical treatment are active individuals in sports or jobs with heavy manual work that requires pivoting or pushing off with the knee. Surgery is also recommended for people with unstable knees or injuries combined with damage to the menisci, articular cartilage, joint capsule, or ligaments.

Prior to surgery, most people participate in physical therapy. Swelling can make the knee stiff. Immobility can cause the muscles and ligaments to shorten. Your physical therapist will help you stretch your knee to regain full movement. If your collateral ligaments are involved, you may need to wear a brace to allow them to heal prior to your surgery. These steps will help you prepare for a successful recovery after your surgery.

The goal of ACL repair is to reconstruct your knee joint to restore its function and stability, and prevent further injury. During surgery, your doctor will replace your damaged ACL with a healthy tendon, called a graft. There are several options for acquiring grafts. They may be taken from an area near your knee or from a donor cadaver.

A patellar tendon autograft uses the middle third of the patellar tendon and bone plugs from the shin and kneecap. This type of reconstruction is most often recommended for high-demand athletes and individuals that do not have to perform a lot of kneeling activities. This grafting procedure has been considered the “gold standard” for ACL repair.

A hamstring tendon autograft uses one or two tendons from the hamstring muscles at the inner side of the knee. The hamstring tendon autograft is most appropriate for lighter-weight individuals with a small patella bone and a history of pain. This method can be associated with a faster recovery. 

A quadriceps tendon autograft uses the middle third of the quadricep tendon and a bone plug from the upper end of the kneecap. The quadricep graft is large. It is most appropriate for taller and heavier individuals. It is also used for individuals with prior failed ACL reconstructions. Because it is a large graft, this method uses a larger incision.

Allografts are tendon grafts taken from cadavers. Allografts are most appropriate for older individuals that are moderately active or those with a history of pain. It is also used for individuals with prior failed ACL reconstructions, those attempting to return to sports more quickly, and those that need more than one ligament reconstructed.  Because the graft is not taken from the individual, this method is associated with less pain, smaller incisions, and a shorter surgery time.

Many ACL reconstructions are performed as outpatient procedures. You can be anesthetized for surgery or receive a nerve block to numb your knee and leg area.  After you have received your anesthesia and your leg is relaxed, your doctor will examine your knee by performing similar  tests that were done in your clinical examination. This provides your doctor with more information about your knee and helps to formulate the surgical plan.

Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert an arthroscope and will reposition it to see your joint from different angles.

An arthroscope is a very small surgical instrument. It is about the size of a pencil. An arthroscope contains a lens and lighting system that allows a surgeon to see inside of a joint. The surgeon only needs to make small incisions and the joint does not have to be opened up fully. The arthroscope is attached to a miniature camera. The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.  

Your surgeon may make additional small incisions and use other slender surgical instruments if you are having your meniscus, cartilage, or ligaments repaired or removed. Your new graft will be attached using surgical hardware. Your surgeon will test the new graft and your knee function. Again, your doctor will examine your knee by performing similar muscle tests that were done in your clinical examination. This is to ensure that your knee is stable and has full range of motion. In addition to bandages, some surgeons apply a knee brace or a cold therapy device to help reduce swelling at the completion of your surgery.

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Recovery

You will most likely go home on the same day of your surgery. You will receive pain medication to make you feel as comfortable as possible. In some cases, ice is applied to the knee throughout the day to help to reduce pain and swelling. Your doctor may prescribe blood thinning medication and special support stockings. You should keep your leg elevated and move or pump your foot and ankle.

In some cases, doctors prescribe compression boots and a continuous passive motion (CPM) machine. Compression boots are inflatable leg coverings that are attached to a machine. They work to gently squeeze your legs to aid blood circulation. A CPM machine will move your leg in a cycling motion while you are in bed. The CPM machine is helpful to improve circulation, decrease swelling, and restore movement in your knee. 
 
Walking and knee movements are very important to your recovery. Exercising will begin immediately after your surgery. You will begin physical therapy soon after your surgery. Your first goals will include straightening your knee and strengthening your quadriceps muscles.  
 
At first, you will need to use a walker or crutches while standing and walking. Your doctor may also prescribe a knee brace for you to wear during activities. Your physical therapist will help you walk and show you how to go up and down stairs. You will also learn ways to exercise to further strengthen your quadriceps and hamstring muscles and regain balance and coordination. It can take up to four to six months to restore proprioception and coordinated leg movements.
 
An occupational therapist can show you ways to dress and bathe within your movement restrictions. Your therapists can also recommend durable medical equipment for your home, such as a raised toilet seat or a shower chair. The equipment may make it easier for you to take care of yourself as you heal and help to prevent further injury.

The success of your surgery will depend, in part, on how well you follow your home care instructions and participate in exercise during the weeks following your ACL reconstruction. You may need a little help from another person during the first few days at home. If you do not have family members or a friend nearby, talk to your physician about possible alternative arrangements. 
 
Recovery times differ depending on the severity of your injury, the type of procedure that you had, and your health at the time of your injury. Your doctor will let you know what to expect. Generally, you should be able to resume some of your regular activities in one to three weeks after your procedure and progress to full sporting activity in about six months. Overall, you should notice a steady improvement in your strength and endurance over the next six to twelve months. The majority of people are able to resume functional activities after ACL reconstruction.

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Prevention

It is important that you adhere to your exercise program and safety precautions when you return home. You should stay as active as possible. It is especially important to keep your quadriceps and hamstrings very strong. You should also continue to use the durable medical equipment as advised.

It is also important to avoid injuring your ACL again. Depending on your injury, your surgeon may provide you with temporary or permanent activity or lifting restrictions. In some cases, specialized knee braces may be recommended for specific activities.

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Introduction

Total ankle replacement surgery, or ankle arthroplasty, can improve ankle function and relieve severe pain caused by arthritis and other conditions. As more FDA-approved ankle implants have become available, ankle replacement has become the preferred alternative to ankle fusion. People with severe ankle pain from injuries or arthritis are ideal candidates for ankle replacement surgery.

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Anatomy

Your feet and ankles are extremely complex, including 26 bones, 33 joints, 107 ligaments, and 19 muscles. The ankle joint is where the leg and foot bones meet. The bones are coated with a smooth material called cartilage, and surrounded by strong ligaments. The cartilage minimizes friction as the bones glide on each other. The ligaments are bands of supportive tissue that provide stability and flexibility for range of motion, which is necessary for walking, running, and other activities.

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Causes

The need for ankle replacement is usually severe arthritis or injury. When cartilage is damaged because of injury or arthritis, the result is pain and swelling in the ankle area. According to the American Academy of Orthopedic Surgeons, about 2 million Americans visit the doctor for ankle pain caused by arthritis or fractures every year. Thousands of people suffer from disabling ankle arthritis, where the cartilage is worn away almost completely. Ankle injuries are common in sports or exercise, because of the added stress on the joint. A history of ankle fractures, osteoarthritis, rheumatoid arthritis, and even obesity can increase your risk for ankle replacement.

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Symptoms

Common symptoms of ankle arthritis or injury include pain, swelling, stiffness, and tenderness around the ankle. You may also notice weakness or instability when you try to put weight on the ankle or foot, making it difficult to stand or walk. In cases of arthritis, the symptoms usually get progressively worse over time. In cases of injury, the symptoms may appear immediately or within a few hours.

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Diagnosis

A physical examination of your ankle is the first step in diagnosis. The doctor will evaluate your range of motion and the amount of pain and swelling you are experiencing. Gentle pressure may be applied to pinpoint the source of your pain. An x-ray will be used to look for fractures, bone spurs, and damage to the cartilage. MRI or CAT scans are sometimes needed to gain more information on the condition of your ankle. Your primary doctor can do a basic evaluation, but a certified foot/ankle surgeon is the most qualified to diagnose these conditions.

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Treatment

If rest, heat/ice therapy, physical therapy, and anti-inflammatory medication do not improve your symptoms, consulting with an orthopedic surgeon who specializes in foot/ankle conditions is recommended. If the surgeon finds evidence of a poorly healed complex fracture or advanced (end-stage) arthritis, you may need ankle arthroscopy, ankle fusion, or a total ankle replacement.

Ankle arthroscopy can treat soft tissue injuries and minor arthritis, but severe ankle arthritis should be addressed by fusion or replacement. Ankle fusion will reduce the range of motion in your ankle, but for many cases of ankle arthritis, total ankle replacement is appropriate.

Ankle replacements have been around for decades, but early designs had limited success due to the complexity of the anatomy. Modern ankle replacements have made the surgery more successful. Orthopedic surgeons can match patients with an implant specifically designed to fit their ankle, which leads to better surgical outcomes and quality of life after ankle replacement surgery.

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Surgery

Total ankle replacement is also known as total ankle arthroplasty, or TAA. The procedure involves rebuilding the ankle joint with metal and plastic components. Additional surgery on tendons may also be done to improve the range of motion in your ankle. The surgery can sometimes be performed as an outpatient. Surgery is followed by post-operative rehabilitation.

You might be a candidate for ankle arthroplasty if you have osteoarthritis or rheumatoid arthritis that does not respond to conservative management; or if you need an ankle fusion but want to maintain full range of motion in your joint.

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Recovery

After surgery, you will work with a physical therapist to gradually strengthen and condition your ankle and return to your desired activity level. Most people make a full recovery within 6 to 12 months after surgery. Ankle replacement surgery enables you to achieve range of motion, increase function, and return to a more active lifestyle, with little or no pain. Thanks to improvements in modern ankle implants and techniques, ankle replacement surgery results have greatly improved.

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Introduction

Ankle Sprains are a very common injury that can happen to anyone.  Our ankles support our entire body weight and are vulnerable to instability.  Walking on an uneven surface or wearing the wrong shoes can cause a sudden loss of balance that makes the ankle twist.  If the ankle turns far enough, the ligaments that hold the bones together can overstretch or tear, resulting in a sprain.  A major sprain or several minor sprains can lead to permanent ankle instability.

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Anatomy

The bones in our leg and foot meet to form our ankle joint. The leg contains a large bone, called the Tibia and a small bone called the Fibula.  These bones rest on the Talus bone in the foot.  The Talus bone is supported by the Calcaneus bone, our heel.  Our heels bear 85% to 100% of our total body weight. 
 
Strong tissues, called ligaments, connect our leg and foot bones together.  One ligament, called the Lateral Collateral Ligament (LCL), is very susceptible to ankle sprains.  The LCL is located on the outer side of our ankle.  It contributes to balance and stability when we are standing or walking and moving.  The LCL also protects the ankle joint from abnormal movements, such as extreme ranges of motion, twisting, and rolling.
 
The LCL is composed of three separate bands commonly referred to as separate ligaments.  The Anterior Talofibular Ligament is the weakest and most commonly torn, followed by the Calcaneofibular Ligament.  The Posterior Talofibular Ligament is the strongest and is rarely injured.

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Causes

Our ankles are susceptible to instability, especially when walking on uneven surfaces, stepping down at an angle, playing sports, or when wearing certain shoes, such as high heels.  Everyone, even the fittest athlete, is vulnerable to a sudden loss of balance under these conditions.  Our ankles support our entire body weight.  When the foot is placed at an abnormal angle, the weight of our body places an abnormal amount of force on the ligaments causing them to stretch.  When a ligament is forced to stretch beyond its limit, it may overstretch, tear, or disconnect from the bone.

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Symptoms

You may lose your balance and fall if your foot is placed at a poor angle on the ground.  Some individuals may hear a “pop” noise when the injury takes place.  You will probably have difficulty putting weight on your foot or walking.  Pain is usually the first symptom of a Sprained Ankle.  Swelling, stiffness, and skin discoloration from bruising may occur right away or take a few hours to develop.

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Diagnosis

Your doctor can diagnose a Sprained Ankle by conducting a physical examination and asking you what happened to cause the injury.  Your doctor will move your ankle in various positions to determine which ligament was injured.  Your ankle may be X-rayed to make sure that you do not have a broken bone in your ankle or foot.  In severe cases, a Magnetic Resonance Imaging (MRI) scan may be ordered to view the ankle structures in more detail.  The X-ray and the MRI scan are painless and require that you remain very still while the images are taken.
 
Ankle Sprains are categorized by the amount of injury to the ligaments.  A Grade One sprain has minimal impairment.  The ligament has sustained slight stretching and some damage to the fibers.  A Grade Two sprain is characterized by partial tearing of the ligament.  The ankle joint is lax or looser than normal.  A Grade Three Spain describes a complete tear of the ligament.  The ankle joint is completely unstable.

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Treatment

The majority of Ankle Sprains heal with non-surgical treatment methods.  It is imperative that you seek evaluation and treatment for any ankle injury, as sometimes fractures are mistaken for sprains.  
 
The treatment of an Ankle Sprain depends on its Grade.  Grade One sprains are treated with the RICE method - Rest, Ice, Compression, and Elevation.  You should rest your ankle by not placing weight on it.  You may use crutches to help you walk.  Applying ice packs to your ankle can help keep the swelling down and reduce pain.  You should apply ice immediately after spraining your ankle.  Your doctor will provide you with a continued icing schedule.  Your doctor may recommend over-the-counter or prescription pain medication.  Compression bandages, such as elastic wraps, are helpful to immobilize and support the ankle.  You should also elevate your ankle at a level above your heart for 48 hours to help reduce swelling.
 
Care for Grade Two sprains includes applying the RICE method of treatment and in most cases your doctor will prescribe an ankle air cast or soft splint for positioning and stability.  As healing takes place, your doctor will gradually increase your activities.  Your doctor may recommend that you wear an ankle brace for stability as your healing continues.  
 
In addition to the primary care, your doctor may recommend a short leg cast or a cast-brace system for a Grade Three sprain.  The cast is typically worn for two or three weeks and followed by rehabilitation.  Rehabilitation is helpful to decrease pain and swelling and to increase movement, coordination, and strength.  Your doctor may recommend customized inserts called orthotics for your shoe or special shoes to help you maintain proper ankle positioning.
 
The recovery time is shorter for ankle sprains that do not require surgery.  Grade One sprains may heal in about six weeks.  Grade Two and Three Sprains may take several months to heal.  Grade Three Sprains usually involve a period of physical therapy to promote healing.

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Surgery

Ankle Sprains rarely require surgery; however, it is an option when non-surgical treatments and rehabilitation fail.  Your physician will evaluate each case of Ankle Sprain on an individual basis.  Your physician will discuss surgical options and help you determine the most appropriate choice for you. 
 
One type of surgery, termed Ligament Tightening, is performed to tighten the overstretched ligaments.  This usually involves the Anterior Talofibular Ligament (ATFL) and the Calcaneofibular Ligament (CFL).  The surgeon will make an opening over the ligaments and separate the ATFL and the CFL in half.  The ends of these two ligaments are surgically attached to the Fibula.  The surgeon will further reinforce the ligaments by also attaching the top edge of the Ankle Retinaculum.  The Ankle Retinaculum is a large band of connective tissue located at the front of the ankle.
 
If the ligaments are severely damaged or not appropriate for a Ligament Tightening procedure, the surgeon may perform a Tendon Graft.  For this procedure, the surgeon will use a portion of a nearby tendon for a tendon graft.  The tendon from the Peroneus Brevis muscle in the foot is most commonly used.  The tendon graft is surgically attached to the Fibula and the Talus, near the attachment sites of the original tendon. 
 
In some cases of chronic pain, an Arthroscopic Surgery may be performed to remove bone fragments, scar tissue, and damaged cartilage.  Arthroscopic surgery uses a small camera, called an arthroscope, to guide the surgery.  Only small incisions need to be made and the joint does not have to be opened up fully.  This can shorten the recovery time.

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Recovery

Depending on the grade of the injury and what surgical or non-surgical methods are applied to repair the ankle, will determine the rate of recovery.  
 
Grade 1 sprains should only experience slight limits to range of motion, and the recovery process is approximately six weeks.
 
Grade 2 sprains experience moderate impairment and recovery may take a few months.  
 
Grade 3 sprains have severe impairment and may take several months to fully recover.  Even after a full recovery, some patients find that swelling still might occur. In most cases, rehabilitation will help restore strength, mobility and range of motion.

Recovery from surgery differs and depends on the extent of your injury and the type of surgery that was performed.  Your physician will let you know what to expect.  Individuals usually wear a cast for up to 2 months following surgery.  Your doctor will instruct you to carefully increase the amount of weight that you put on your foot.  Rehabilitation following surgery is a slow process.  Individuals typically participate in physical therapy for two to three months.  Physical therapy helps to strengthen the ankle muscles and increase movement.  Success rates are high for both surgical procedures.  The majority of individuals achieve an excellent recovery in about six months.

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Prevention

Individuals that experience one ankle sprain are at an increased risk to experience another.  It may be helpful to wear shoes that provide extra ankle support and stability.  Shoes with low heels and flared heels may feel steadier.  In some cases, doctors recommend a heel wedge or prescribe an orthosis, a plastic brace, to help position the foot inside of the shoe.

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Introduction

When you need surgery to replace a damaged or diseased hip, some orthopedic surgeons have advanced training to perform anterior hip arthroplasty, also known as the direct anterior approach to hip replacement. This procedure is considered less invasive, as it spares the surrounding muscles that support the joint and minimizes scarring, pain, and down time. Patients can begin rehabilitation sooner and recover faster after having anterior hip replacement, compared to more traditional posterior hip replacement.

If you have suffered an injury due to a fall or have sudden onset of hip pain, seek medical attention immediately. If your pain is chronic, you should see a hip specialist for a complete evaluation of your symptoms.

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Anatomy

Your hip is a ball-and-socket joint, where the pelvis and thigh bones meet on the left and right sides of the body. The hip joints are surrounded by supportive tissues including muscle, ligaments, and tendons to provide stability while allowing for movement. The bones are covered with cartilage, which forms a smooth surface for bones to glide across when we move.

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Causes

There are several reasons for the need for hip replacement. Arthritis is one of the most common. Cartilage may deteriorate with age, leading to bone-on-bone rubbing. When this occurs in the hip, walking and other movements we take for granted can become extremely painful. Other forms of arthritis, such as rheumatoid arthritis and psoriatic arthritis, can lead to the need for hip replacement. Certain types of hip fracture are sometimes best treated with hip replacement.

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Symptoms

Pain, stiffness, or limited mobility are common symptoms of hip arthritis. Most often, the pain is felt in the groin, thigh, or in your knee. You may notice a feeling like your leg might give out when you take a step.

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Diagnosis

An evaluation of your hips begins with a comprehensive exam and X-rays. The X-ray will look for narrowing of the joints, bone spurs, and bone cysts that sometimes form in arthritic joints. In certain circumstances, your doctor may also order an MRI. 

During the exam, the doctor will ask about your symptoms and how long your hip has been bothering you. You will need to demonstrate some movements, such as walking, bending, or standing up. This will help the doctor pinpoint the areas that need to be further examined.

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Treatment

Unless you have an immediate need for surgery, the primary treatment will employ the most conservative, non-surgical options. Medication, rest, and exercises including physical therapy can be effective for treatment of hip arthritis and minor sprains and strains.

When conservative treatments fail to provide sufficient relief of your symptoms, you and your doctor may consider a surgical procedure to repair damage to the joint or replace the joint with an artificial implant (prosthetic hip). The extent of damage, your age, and activity level can help your surgeon decide if you are a candidate for surgery.

Many patients with severe hip damage caused by arthritis are candidates for anterior hip replacement surgery. Even large or obese patients can have a successful outcome with this muscle-sparing procedure. However, large size makes the operation more challenging.

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Surgery

Anterior hip arthroplasty is an advanced orthopedic procedure used to replace a damaged hip by making an incision on the front (anterior) side of the hip.

Traditionally, hip replacement surgery begins with an incision to the side or back of the hip area. With the anterior approach, having the incision on the front of the hip prevents any discomfort in the incision area when sitting down or lying on your side.

This approach also allows the surgeon to leave your muscles and ligaments intact while replacing the hip joint. This can decrease the chance of the joint popping out of place (dislocating). Lastly, a smaller incision is needed than would be for a posterior or side approach.

Many orthopedic surgeons prefer the anterior approach to hip replacement because of these advantages.

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Recovery

Compared to other approaches, the anterior hip arthroplasty is associated with shorter recovery times. This is because the surgical technique leaves the supportive tissues (muscles, ligaments, tendons) in place to support your hip immediately after the procedure.

Many people can begin post-operative rehabilitation right away and return to their normal activity level within weeks of surgery. Other approaches take longer because the muscles need additional time to heal.

Although the procedure is preferred over more traditional hip replacement, the anterior approach to hip surgery is not yet as widely performed. Advanced training in this technique is required for a successful outcome.

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Introduction

Arthritis is a common disease that causes joint pain, stiffness, immobility, and swelling.  Arthritis is actually a term for a group of over 100 diseases that affect the muscle and skeletal system, particularly the joints.  Arthritis alters the cartilage in joints.  Cartilage is a very tough, shock absorbing material that covers the ends of many of our bones.  The cartilage forms a smooth surface and allows the bones in our joints to glide easily during motion.  Arthritis can cause the cartilage to wear away.  Loss of the protective lining can cause painful bone on bone rubbing.  Arthritis can be quite painful and disabling.  While this may be tolerated with medications, therapy, other modalities, and lifestyle adjustments, there may come a time when surgical treatment is necessary.

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Anatomy

Bones are the hardest tissues in our body.  They support our body structure and meet to form joints.  Cartilage covers the ends of many of our bones and forms a smooth surface for our bones to glide on during motion.  A membrane called synovium lines the joint.  The synovium secretes a thick liquid called synovial fluid.  The synovial fluid acts as a cushion and lubricant between the joints.  It reduces friction between the bones and prevents “wear and tear.”

Ligaments are strong tissues that connect our bones together and provide stability.  Our ligaments are also lined with synovium.  The synovial fluid allows the ligaments to glide easily during movement.  Tendons are strong fibers that attach our muscles to our bones.  The tendons and muscles power the joint and enable us to move.

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Causes

There are over 100 different types of arthritis.  Arthritis can occur for many reasons, including aging, “wear and tear,” autoimmune disease, trauma, and inflammatory disease.  Arthritis usually affects the bones and the joints; however, it can affect other parts of the body, such as muscles, ligaments, tendons, and some internal organs.  Two of the more common types of arthritis, Osteoarthritis and Rheumatoid Arthritis are discussed below.
 
Osteoarthritis is the most common type of arthritis, affecting some 21 million Americans alone.  It causes the cartilage covering the end of the bones to gradually wear away, resulting in painful bone on bone rubbing.  Abnormal bone growths, called spurs or osteophytes can grow in the joint.  The bone spurs add to the pain and swelling, while disrupting movement.  All of the joints may be affected by Osteoarthritis. 

Osteoarthritis is often more painful in the weight bearing joints, including the spine, hip, and knee.  It tends to develop as people grow older.  Osteoarthritis can occur in young people as the result of an injury or from overuse of a joint during sports or work.
 
Rheumatoid Arthritis is one of the most serious and disabling types of arthritis.  It is a long-lasting autoimmune disease that causes the synovium to become inflamed and painful.  It also causes joint swelling and deterioration.  Pain, stiffness, and swelling are usually ongoing symptoms, even during rest.
 
Rheumatoid Arthritis most commonly occurs in the hand and foot joints.  It can also develop in the larger joints, including the hip, knees, and elbows.  Many joints may be involved at the same time.  Further, tissues surrounding the joint may also be affected.  Rheumatoid Arthritis can affect people of all ages, but most frequently occurs in women and those over the age of 30.

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Symptoms

Inflammation is the main finding of arthritis.  Inflammation can cause your joints to feel painful, swollen, and stiff.  These symptoms are most likely continuous, even when you are resting.  Your joints may feel weak or unstable.  You may have difficulty moving and performing common activities, such as walking or climbing stairs.

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Diagnosis

Your health care provider can diagnose arthritis by conducting a physical examination.  You will be asked about your symptoms and level of pain.  Your provider will assess your muscle strength, joint motion, and joint stability.  Blood tests and other laboratory tests may identify what type of arthritis you have.  Imaging tests provide more information about the condition of your joint.

X-rays are used to see the condition of your bones and joints, and to identify areas of arthritis or bone spurs.  The tissues that surround the joint do not show up on an X-ray.  In this case, a Magnetic Resonance Imaging (MRI) scan may be requested to get a better view of the soft tissue structures, such as ligaments, tendons, and cartilage.

A bone scan may be ordered to identify the location of abnormal growths in a bone, such as bone spurs, cysts, or arthritis.  It is a sensitive test that can indicate joint degeneration in early stages that may not yet be visible on plain x-rays.  A bone scan requires that you receive a small harmless injection of a radioactive substance several hours before your test.  The substance collects in your bones in areas where the bone is breaking down or repairing itself.  These imaging tests are painless.

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Treatment

Most cases of arthritis can be treated with non-surgical methods.  Temporary joint rest and pain relievers are sometimes all that are needed.  Over-the-counter medication or prescription medication may be used to reduce pain and swelling.  If your symptoms do not improve significantly with these medications a cortisone injection may be successful in reducing inflammation and pain.

Viscosupplementation is another injection option for arthritis, but currently is FDA approved for use only in the knee.  Studies are underway to test its usefulness in other joints.  Several products are on the market that when injected in a series into the knee can reduce pain by temporarily improving the health of the joint. 
 
Occupational or physical therapists can help you strengthen the muscles surrounding your joint.  The resulting added joint stability can help relieve pain.  Aquatic therapy in a heated pool can be especially soothing.  In addition, the buoyancy of the water takes stress off the joints while exercising, and the resistance of the water can help strengthening efforts.  Your therapists may also apply heat to treat stiffness, and ice to decrease pain.  They may recommend splints, walkers, or canes to help relieve stress on your joints.  The therapists will instruct you on how to do your daily activities, such as housework and meal preparation, in a manner that puts less stress on your joints.

Acupuncture is a time-tested treatment for pain.  Very fine needles are strategically placed around the body to block or interrupt pain pathways.  Acupuncture should be administered by a trained professional, and can often be extremely helpful.

A variety of herbs and nutritional supplements have been shown to be helpful in treating arthritis.  Two of the more commonly known supplements are glucosamine and chondroitin.  They have been studied most in arthritis of the knee, and have shown some good results for treating arthritis in other joints. Some research has also shown that a proper diet consisting of fruits and vegetables, with a minimum of fat, can benefit arthritis.

Exercise regimes, such as yoga, Pilates, and tai chi can improve arthritis pain in many ways.  Physically, the stretching and strengthening provided by these programs has a direct positive effect for many with arthritis.  Additionally, the stress-reducing relaxation that usually occurs from these types of exercise can have a significantly positive effect on arthritis pain.

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Surgery

Because arthritis is a degenerative and progressive disease, it may get worse over time.  When non-surgical treatments no longer provide relief, surgery may be recommended.  The type of surgery that you receive will depend on your type of arthritis, its severity, and your general health.  Your doctor will discuss appropriate surgical options to help you decide what is best for you.
 
There are several types of surgical procedures for arthritis.  The surgeon may remove the diseased or damaged joint lining (synovium) in an operation called a synovectomy.  The bones in a joint may be realigned with a procedure called an osteotomy.  The bones in a joint may also be fused together to prevent joint motion and relieve pain.
 
In advanced arthritis, the damaged joint can be replaced with an artificial one.  Artificial joints are made of metal, plastic, ceramics, or a combination of the materials.  The material selected depends on the reason for the surgery, as well as which joint is being replaced.  Joint replacement can provide significant pain relief and improved mobility.

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Recovery

Recovery from arthritis surgery is very individualized.  Your recovery time will depend on the extent of your condition, the joint that was involved, and the type of surgery that you had.  Your doctor will let you know what you may expect.
 
Generally, traditional open joint surgeries take several months to heal, depending on the joint.  Minimally invasive surgery and arthroscopic surgery use smaller incisions and typically heal in a shorter amount of time, from several weeks to a few months.  Your doctor may restrict your activity for a short time following your surgery.  In most cases, rehabilitation is recommended to mobilize and strengthen the joint.

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Prevention

Some types of arthritis and arthritis symptoms may be prevented.  It is important to know what type of arthritis you have and to ask your health care provider what you can do to prevent symptoms.  For example, for some types of arthritis it is helpful to reduce your weight or stop performing repetitive joint movements.  It may be helpful to consult an occupational or physical therapist to learn how to use proper body mechanics to protect your joints during your daily activities. 
 
Assistive devices, such as a walker, shower chair, or raised toilet seat may enable you to perform tasks while minimizing the stress on your joints.  It may also be helpful to participate in aquatic therapy in a heated pool or exercise to keep your joints strong.

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Treatment

Your doctor can administer Arthrocentesis procedures in his or her office or at bedside in a hospital.  Your injection site will be sterilized and anesthetized.  Your doctor will use a needle and syringe to aspirate or pull fluid from the site.  Your doctor may inject pain relieving or corticosteroid medications.  The aspirated fluid will be sent to a lab for examination.  Your doctor will contact you with the results.

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Introduction

A Bennett’s fracture occurs when the bone at the base of the thumb breaks and dislocates.  It results from a forceful injury, such as during fist fighting, playing football, accidents, or a fall.  A Bennett’s fracture causes thumb swelling, pain, and immobility.  Treatment entails realigning the broken bone and providing stabilization while it heals.

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Anatomy

The metacarpal bone at the base of your thumb and the trapezium bone in your wrist meet to form the carpometacarpal (CMC) joint.  Smooth cartilage covers the ends of the metacarpal and trapezium.  The cartilage allows the bones to glide easily during motion.  Strong ligaments and muscles hold the CMC joint in position and provide a combination of mobility and stability.
 
Your thumb joint is the only joint in your hand that can move in all directions.  Your thumb can move up and down, in and out, and rotate slightly to touch your fingers (opposition).  You move your thumbs hundreds of times each day. The movements of the thumb allow it to work as an anchor to help the fingers hold objects.  The thumb works as a grip when you use a hammer or hold a glass.  The thumb also acts as a stabilizer to allow your fingers to manipulate items.  You use such precision movements for such activities as counting coins and handwriting. A tendon that attaches to the base of the thumb metacarpal, called the abductor pollicis longus, is responsible for the joint dislocation that can occur with a Bennett’s fracture.

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Causes

A Bennett’s fracture occurs when the metacarpal bone in the thumb breaks and dislocates at the base of the thumb.  Forces that impact the bent thumb cause this injury.  Bennett’s fractures can result from any significant forces placed on the base of the thumb, such as sports, falls and accidents.

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Symptoms

A Bennett’s fracture causes your thumb to feel painful and stiff.  Your thumb area will swell.  Your thumb may be unstable and therefore difficult to move normally.  Over time, it is common for an old poorly treated Bennett’s fracture to develop arthritis.  This is because the joint at the base of the thumb was not realigned properly.

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Diagnosis

Your doctor can diagnose a Bennett’s fracture by examining your hand and taking X-rays.  In some cases, a computed tomography (CT) scan may be used to provide a more detailed image.

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Treatment

Small uncomplicated fractures, without displacement of the bone fragments, are treated non-surgically.  This means that the bones can be held in the correct alignment without surgically opening the skin.  In this case, a splint and or a cast is used.  A thumb spica cast or splint is worn to maintain positioning while the Bennett’s fracture heals.  Fractures that require realignment are reduced surgically and stabilized with pins, screws or plates.

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Surgery

A Bennett’s fracture can also be treated with open reduction and internal fixation (ORIF).  This means that an incision is made at the base of the thumb.  Surgical hardware, such as screws , pins or plates are used to align the fracture to allow it to heal in the correct position.  A thumb spica cast or splint is worn for several weeks following surgery.  Therapy for range of motion of the thumb is started when your doctor determines it is safe to do so.

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Recovery

Casts are usually worn for four to six weeks.  Once removed, you will participate in hand therapy exercises to increase the mobility, flexibility, and strength in your hand.  Generally, Bennett’s fractures caused by low impact forces have better outcomes than injuries caused by high forces.

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Introduction

A boutonniere deformity occurs when the tendon that straightens the middle joint of your finger is injured, weakened or stretched.  The injury allows the middle finger joint to bend (flex) and the end finger joint to pull back and hyperextend.  This makes the finger appear crooked. 

A boutonniere deformity can cause pain and loss of function.  Treatments include splinting, hand therapy, and surgery.  When treated promptly, conditions tend to have the best outcomes.

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Anatomy

Your fingers are made up of three bones called phalanges.  Two joints separate the phalanges.  The distal interphalangeal (DIP) joints are located near your fingertips.  The proximal interphalangeal (PIP) joints are located in the middle of your fingers.  The extensor tendons allow your fingers to extend and straighten.  

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Causes

A boutonniere deformity occurs when the extensor tendon attachment at the central slip on the middle phalanx is injured.  The PIP joint is not able to straighten and remains bent (flexed).  The DIP joint is pulled back into hyperextension by the extensor mechanism that has become out of balance.  This results in a crooked and poorly functioning finger. 

Arthritis, burns, Dupuytren’s contracture, and injuries, can disrupt the extensor tendon.  The tendon may partially or completely tear.  The extensor tendon can remain intact but pull a piece of bone away from where it attaches on the phalanx, also called an avulsion fracture.

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Symptoms

A boutonniere deformity can cause your PIP joint to feel painful and swollen.  You may not be able to straighten out your PIP joint.  Your DIP joint may be hyperextended, causing your finger to look crooked.

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Diagnosis

Your doctor can diagnose a boutonniere deformity by examining your hand.  X-rays will be taken to check for  fractures and the condition of the joints. 

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Treatment

Some boutonniere deformities can be treated with splinting.  Splinting can help certain new and old injuries.  There are many types of splints for boutonniere deformities.  Hand therapy is especially important to ease symptoms and gain functioning.  Splinting is usually tried for at least six weeks.

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Surgery

Surgery may be necessary to reconstruct a tendon or joint.  If past treatments and surgery fail, the bones in the finger can be surgically fused together and kept from moving.  All types of surgeries are followed by splinting and hand therapy.

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Recovery

Recovery from boutonniere deformity surgery can take three to four months.  It can take up to six months for a full recovery.  Recovery is individualized and your doctor will let you know what to expect.

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Prevention

You should contact your doctor if you notice you are developing a boutonniere deformity.  In most cases, early treatment is associated with the best outcomes.  Following treatment, your hand therapist can recommend ways to perform your regular activities to help you avoid future injuries. 

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Introduction

A Boxer’s fracture occurs when the bone at the knuckle of the little finger breaks.  It can result from a forceful injury during fist fighting or hitting a solid object, such as a wall.  A Boxer’s fracture causes swelling, pain, and stiffness.  Treatment involves realigning the broken bone, when necessary, and providing stabilization while it heals.

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Anatomy

The "knuckle" of the fifth finger (small finger or "pinky") is comprised of the head of the metacarpal bone from the hand, and the base of the finger, called the proximal phalanx.  The main function of your little finger is to contribute to a tight strong grip.

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Causes

A Boxer’s fracture occurs when the neck of the metacarpal bone in the little finger breaks commonly caused by punching an immovable object, such as a wall, or someone’s jaw or head during a fist fight.  The impact can cause the bone to break in several different patterns and pieces.

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Symptoms

A Boxer’s fracture can cause your little finger and knuckle area to feel painful.  Your pain may increase with movement.  The hand may swell and bruise.  The normal contour of the "knuckle" may deform or seem to disappear.  This occurs when the fracture bends the bone, and the metacarpal head is no longer prominent.  A Boxer’s fracture can make your little finger feel stiff.  It may not move correctly.  Your little finger may overlap your ring finger when you bend it because of malrotation.  Your grip may be weaker and less coordinated than before.

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Diagnosis

Your doctor can diagnose a Boxer’s fracture by examining your hand and taking x-rays of your hand.  X-rays can show the type of fracture and any dislocation.  In rare cases, a computed tomography (CT) scan may be used to provide a more detailed image.

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Treatment

Many Boxer’s fractures can be treated by immobilizing the joint to promote healing.  Immobilization can be achieved with a variety of splints, a cast, or taping techniques.  “Buddy-taping” involves taping the little finger to the ring finger.

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Surgery

Surgery is recommended for Boxer’s fractures if large degrees of angulation or displacement occur, or if the joint surface is misaligned.  Displacement and angulation means that a piece or pieces of the metacarpal bone that has broken have moved out of position.  An open reduction and internal fixation (ORIF) surgery allows surgical hardware, such as wires and screws, to be placed in the bone to align the fracture and allow it to heal in the correct position.

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Recovery

Rehabilitation with a hand therapist usually follows immobilization and surgery.  It typically takes four to six weeks for a hand fracture to heal and many additional weeks for it to regain motion and strength.  You should avoid heavy lifting, gripping, and contact sports for about three months.  People that have surgery generally require longer recovery periods than people that do not have surgery.  Overall, Boxer’s fractures that are appropriately treated have very good results.

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Prevention

You can avoid Boxer’s fractures by avoiding the situations that cause them.  You should avoid bare fist fighting.  Gloves can protect your hands while boxing.  You should tell your doctor if you hit solid objects, such as walls, when you are angry or frustrated.  Your doctor will be happy to refer you to resources that can help you learn more positive coping skills.

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Introduction

Bunions are a common foot deformity, especially in females.  They most frequently result from wearing shoes that are too small and or have a high heel.  Abnormal pressure from poor fitting shoes causes the bones in the big toe and foot to move out of position.  This results in a large painful bump on the side of the foot at the big toe.

Simply changing to wide shoes with a low heel can treat some bunions.  If non-surgical treatments fail, surgery may be necessary to restore normal alignment, pain-free movement and function.  There are numerous surgical techniques for treating bunions, and the majority of people experience good results.

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Anatomy

The base of the bone in your big toe (proximal phalanx) meets with the head of the metatarsal bone in your foot to form the metatarsophalangeal joint.  Ligaments connect the two bones together.  Tendons attach muscles to the bones and allow movement.  The metatarsophalangeal joint bends whenever you walk.

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Causes

Bunions are a common foot condition.  The vast majority of bunions occur in females, but they may develop in males, as well.  Most bunions result from pressure caused by shoes that are too small, narrow, pointed, or have a high heel.  Bunions can run in families.  Arthritis, particularly osteoarthritis, and polio can contribute to bunion formation.
 
A bunion occurs when the bones at the base of the big toe move out of alignment.  The big toe may lean toward or move underneath the second toe.  The second toe may move out of alignment and overlap the third toe.  Long term irritation causes the base of the big toe to enlarge and a fluid-filled sac may form.  This creates a large bump on the side of the foot at the joint.

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Symptoms

A bunion causes the base of your big toe to stick out and form a bump on the side of your foot.  A bunion can be large, red, swollen, and painful.  The skin on the bottom of your foot may thicken and form a painful callus.  It may hurt to bend your toe, walk, or wear shoes.
 
A bunion causes your foot to look different.  Your big toe may lean towards your second toe.  The first few toes on your foot may lean and overlap. 

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Diagnosis

Your doctor can diagnose a bunion after reviewing your medical history, examining your foot, and taking X-rays of your foot.  X-rays will show the alignment and condition of your bones.  You should tell your doctor about your symptoms and concerns.

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Treatment

Simply changing shoes may treat some bunions.  It is helpful to wear wide-toed shoes with low heels.  Good foot care and felt or foam pads worn between the toes or on the foot may help protect the area and prevent further discomfort.  Custom-made shoe inserts can help position the toe and relieve pain.

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Surgery

If non-surgical treatments fail, surgery may be necessary to restore normal alignment, pain-free movement and function.  Bunion surgery is used to realign the bones, joints, tendons, ligaments, and nerves.  The toes are placed in their correct positions and the bony bump is removed.  There are numerous surgical techniques for treating bunions.  Your doctor will discuss the most appropriate options for you.
 
Bunion surgery is an outpatient surgical procedure.  An ankle-block anesthesia or general anesthesia may be used so that you do not feel pain during the procedure.  Following the surgery, the bones are held in position with wires, screws plates, or cast while they heal.  

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Recovery

You should keep your foot elevated the first few days following your surgery, and apply ice packs as directed.  A special cast or orthopedic shoe will protect your foot as it heals.  You will temporarily need to use crutches, a walker, or cane as you gradually increase the amount of weight you can put on your foot.  Physical therapy can help to restore strength and motion.  It can take many weeks to recover from bunion surgery.  The majority of people have good outcomes.

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Prevention

You may prevent bunions by wearing shoes that fit correctly.  It is beneficial to wear wide, low heel shoes.  Following bunion surgery, you can prevent future bunions by wearing the same type of shoes.  Wearing improper shoes can cause bunions to recur.

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Introduction

A bunionette is a bump that occurs near the base of the little toe on the foot.  They are not as common as bunions, a similar condition that develops near the base of the big toe.  However, people with bunionettes often have bunions as well.

Bunionettes are also known as tailor bunions because years ago, tailors sat cross-legged all day, putting pressure on the side of their foot.  Today, pressure from poor fitting shoes is a common cause of bunionettes, as well as inherited bone structure problems.  There are a variety of non-surgical options for treating bunionettes.  If such treatments fail, surgery may be necessary.

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Anatomy

The base of the bone in your little toe (proximal phalanx) meets with the head of the metatarsal bone in your foot to form the metatarsophalangeal joint.  Ligaments connect the two bones together.  Tendons attach muscles to the bones and allow movement.  The metatarsophalangeal joint bends whenever you walk or move your toe.

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Causes

The most frequent cause of bunionettes is poor fitting shoes that put pressure on the foot structures.  Shoes with tight narrow toes can cause bunionettes, and for this reason, the condition is more likely to develop in women than in men.  Additionally, some people have an inherited foot structure with long bones that tend to bow and form bunionettes.

A bunionette occurs when the bones at the base of the little toe move out of position.  Long-term irritation causes an enlargement that looks like a bump on the little toe.

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Symptoms

A bunionette causes a bump at the base of your little toe on the side of your foot.  The bump can be red, swollen, and painful.  Your skin may become irritated and break open or bleed.  Infections are a concern, especially for people with diabetes. Walking, bending your toe, or wearing shoes may make your symptoms worse.

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Diagnosis

Your doctor can diagnose a bunionette after reviewing your medical history and examining your foot.  X-rays may be taken to show the alignment and condition of your bones.  You should tell your doctor about your symptoms and concerns.

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Treatment

There are a variety of non-surgical treatments for bunionettes.  Simply changing shoes can help.  Select shoes with a wide toe area and low heels.  Avoid high heels and pointed toe shoes.  Pads can help to reduce pressure and pain.

Your doctor may recommend over-the-counter anti-inflammatory medications, such as ibuprofen.  Your doctor may inject corticosteroid medication to reduce inflammation around the joint.  You may also receive instructions for applying ice packs to the area.

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Surgery

If non-surgical treatments fail, surgery may be necessary to allow pain-free movement and function.  Bunionette surgery is used to realign the bones and joint.  During surgery, the toe is placed in the correct position and the bump is removed.  Following surgery, the bones are held in position with surgical hardware while they heal.  Bunionette surgery is usually an outpatient procedure.

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Recovery

You should keep your foot elevated for the first few days following your surgery, and apply ice packs as directed.  You will need to temporarily use crutches, a walker, or cane as you gradually increase the amount of weight you can put on your foot.  It can take weeks to recover from bunionette surgery, and your doctor will let you know what to expect.

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Prevention

You may prevent bunionettes by wearing shoes that fit correctly.  Select wide toe, low heel shoes.

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Introduction

Carpal instability occurs when the small bones in the wrist move out of position and compromise joint functioning.  This may result when the ligaments that hold the bones together are torn or when the bones are fractured or affected by arthritis.  Carpal instability causes ongoing pain and the loss of wrist functioning.  Symptoms may improve with nonsurgical and surgical methods.

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Anatomy

Your wrist complex contains several small carpal bones aligned in two rows.  A complex set of ligaments connect the bones.  Your carpal bones and the two bones in your forearm form several joints in your wrist.  The joints allow movement and position and change the shape of your hand.  Your wrist joints function to position your hand and fingers for precise movements, such as handwriting, and for gripping, such as holding onto a steering wheel.

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Causes

Carpal instability occurs when the carpal bones move out of position.  Chronic ligament weakening, as with arthritis, or ligament injury, such as from a fall, can cause malalignment of the carpal bones.  Carpal bone fractures and deterioration contribute to carpal instability.  When the carpal bones aligned inaccurately, the joints are unstable and may not function properly.

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Symptoms

Carpal instability can cause ongoing pain in your wrist.  You may experience a snapping or hear a clicking noise when you move your hand from side to side.  Your hand and wrist may feel weak and stiff.  You may be unable to use them for activities.  Over time, your hand may develop arthritis. 

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Diagnosis

Your doctor can diagnose carpal instability by reviewing your medical history and performing an examination.  If you experienced a wrist injury, you should tell your doctor about how it occurred.  

Your doctor will feel the ligaments and bones in your hand to pinpoint the source of pain.  Your doctor will maneuver the carpal bones to diagnose specific areas of instability. 

Your hand will be X-rayed to determine the position and condition of the carpal bones.  You may receive other imaging tests, such as computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, arthrograms and ultrasound. 

Your doctor will classify the instability pattern of your carpal bones.  There are several types of carpal instability patterns, including dissociative carpal instability, nondissociative carpal instability, ulnar translocation, and dorsal subluxation.  Dissociative carpal instability results in instability between the carpal bones that are within a row.  Nondissociative carpal instability is instability that occurs between the two rows of carpal bones.  Ulnar translocation describes a shift in the carpal bones to the little finger side of the hand.  Ulnar translocation can result from rheumatoid arthritis.  Dorsal subluxation describes an upward shift in the carpal bones that can occur after a wrist fracture.

Carpal instability is further classified as static or dynamic.  Static instability is apparent on an X-ray when the hand is motionless.  If a doctor can move the carpal bones during maneuvering tests, it is termed a dynamic carpal instability.

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Treatment

Treatment is specific to the type of carpal instability that you experience.  Treatment depends on many factors, including the condition of the ligaments and bones, and the location of the instability.  Treatment of carpal instability can be a complex process.  Splinting will treat some types of carpal instability but many types of carpal instability require surgery.  Your doctor will discuss your condition and the most appropriate treatment options with you.

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Surgery

There are several types of surgery for carpal instability.  The type of surgery you receive depends on your condition.  Surgery is an option to repair and reconstruct ligaments.  Ligaments can be reconstructed with transferred tendons.  Joints may be fused together and bones may be reshaped to provide support and relieve pain.

Arthroscopic surgery is commonly used to treat carpal instability.  An arthroscope is a very small surgical instrument.  It contains a lens and lighting system that allows a surgeon to view inside a joint.  The surgeon only needs to make small incisions and the joint does not have to be opened up fully.  A miniature camera attached to an arthroscope allows a surgeon to view and record the magnified images on a video screen.  Thin surgical instruments are inserted for surgery.  An arthroscope may be used to reconstruct, trim, and repair torn ligaments.

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Recovery

Surgery to repair carpal instability is usually followed by a period of immobilization with splinting or casting, followed by hand therapy rehabilitation.  Recovery is an individualized process.  Your doctor will let you know what to expect.

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Introduction

Carpal Tunnel Syndrome is a common condition that affects the hand and wrist. It occurs when the Median Nerve in the wrist is compressed. Nerves carry messages between our brains, spinal cord, and body parts. The Median Nerve carries signals for sensation and muscle movement. When the Median Nerve is compressed or entrapped, it cannot function properly. This syndrome has received much attention in the last few years because of suggestions that it may be linked with jobs that require repeated use of the hands. In actual fact, little proof of this exists.

Carpal Tunnel Syndrome is more common in women and people between the ages of 30 and 60 years old. It is the most common nerve entrapment syndrome and affects up to 10% of the population. Individuals with Carpal Tunnel Syndrome may feel numbness, pain, and a “tingly” sensation in their fingers, wrists, and arms. They may have difficulty performing grasping and gripping activities because of discomfort or weakness.

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Anatomy

The Median Nerve passes from the arm, through the wrist, and into our fingers. At the center of the wrist joint, the Median nerve goes through a passageway called the Carpal Tunnel. Our wrist bones form the bottom of the Carpal Tunnel. The Transverse Carpal Ligament covers the top. Ligaments are strong bands of tissues that connect bones together. In addition to the Median Nerve, the Carpal Tunnel also contains many tendons. These tendons attach to the muscles that allow our fingers to bend or flex.

The Median Nerve supplies the sense of feeling to our thumb, index finger, middle finger, and half of the ring finger. It also sends messages to the Thenar Muscles that move the thumb. We use the Thenar Muscles when we position our thumb to grasp and hold objects. When compressed in the Carpal Tunnel, the Median Nerve sends faulty messages as it travels into the hand and fingers.

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Causes

Carpal Tunnel Syndrome develops when the tissues and tendons in the Carpal Tunnel swell and make the area within the tunnel smaller. This can happen in association with other medical conditions, such as hypothyroidism and diabetes. The increased pressure within the tunnel causes the Median Nerve to become compressed. The pressure disrupts the way the nerve works and causes the symptoms of Carpal Tunnel Syndrome. Usually, the exact cause of carpal tunnel syndrome is unknown.

Rheumatoid arthritis, joint dislocation, and fractures can cause the space in the tunnel to narrow. Some women develop Carpal Tunnel Syndrome because of swelling from fluid retention caused by hormonal changes. This may occur during pregnancy, premenstrual syndrome, or menopause.

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Symptoms

The primary symptoms of Carpal Tunnel Syndrome are pain, numbness, and tingling. The numbness and tingling is typically present in the thumb, index, middle, and half of the ring finger. Some people describe the pain as a deep ache or burning. Your pain may radiate into your arms. Your thumb may feel weak and clumsy. You may have difficulty grasping items, and you may drop things. Your symptoms may be more pronounced at night, when you perform certain activities, or in cold temperatures.

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Diagnosis

Your doctor can diagnose Carpal Tunnel Syndrome by conducting a medical examination, reviewing your medical history, and asking you about your activities and symptoms. During the physical exam, your doctor will check your wrist and hand for sensation and perform a thorough hand examination.

Your doctor may ask you to perform a couple of simple tests to determine if there is pressure on the Median Nerve. For the Phalen’s Test, you will firmly flex your wrist for 60 seconds. The test is positive if you feel numbness, tingling, or weakness. To test for the Tinel’s Sign, your doctor will tap on the Median Nerve at the wrist. The test is positive if you feel tingling or numbness in the distribution of the median nerve. Lab tests may be ordered if your doctor suspects a medical condition that is associated with Carpal Tunnel Syndrome. Your doctor may take an X-ray to identify arthritis or fractures.

In some cases, physicians use nerve conduction studies to measure how well the Median Nerve works and to help specify the site of compression. Physicians commonly use a test called a Nerve Conduction Velocity (NCV) test. During the study, a nerve is stimulated in one place and the amount of time it takes for the message or impulse to travel to a second place is measured. Your doctor will place sticky patches with electrodes on your skin that covers the Median Nerve. The NCV may feel uncomfortable, but only during the time that the test is conducted.

An Electromyography (EMG) test is often done at the same time as the NCV test. An EMG measures the impulses in the muscles to identify poor nerve input. Healthy muscles need impulses to perform movements. Your doctor will place fine needles through your skin and into the muscles that the Median Nerve controls. Your doctor will be able to determine the amount of impulses conducted when you contract your muscles. The EMG may be uncomfortable, and your muscles may remain a bit sore following the test.

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Treatment

The symptoms of Carpal Tunnel Syndrome can often be relieved without surgery. Some medical conditions associated with Carpal Tunnel Syndrome can be treated. Some cases respond to treatments that relieve pain and provide rest. Your doctor may recommend that you wear a splint at night to support your wrist in a neutral position.

Splints may also be worn during activities that aggravate your symptoms to position the wrist properly and provide wrist support. Your doctor may suggest over-the-counter anti-inflammatory medication to help reduce your pain and swelling. Sometimes doctors choose to inject corticosteroid medication, an anti-inflammatory medication, to provide symptom relief.  

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Surgery

Surgery is recommended when non-surgical options do not work or if the condition becomes worse. There are a few types of outpatient surgery to remove pressure on the Median Nerve. Your doctor will help you decide which option is best for you.

The standard surgery for Carpal Tunnel Syndrome is called an Open Release. The surgeon will use a local or regional anesthetic to numb the hand area. For this procedure, the surgeon makes a two to three inch opening along the palm. This allows the surgeon access to the Transverse Carpal Ligament, the roof of the Carpal Tunnel. The surgeon makes an incision in the Transverse Carpal Ligament to open the tunnel and make it larger. By doing so, pressure is taken off of the median nerve. The surgery time for an Open Release is short, only about fifteen minutes.

Another surgical option is called Endoscopic Carpal Tunnel Release. This type of surgery is done using an endoscope placed in a small incision. An endoscope is small device with a light and a lens that allows the surgeon to view the Carpal Tunnel without disturbing the nearby tissues. It may be used in conjunction with a camera or video system.

Endoscopic Carpal Tunnel Release most often uses a local or regional anesthetic to numb the wrist and hand area. In some cases, individuals are sedated for the surgery. The surgeon makes a small opening below the crease of the wrist and inserts the endoscope to view the Carpal Tunnel. Some surgeons make a second incision in the palm of the hand. Guided by the endoscope, the surgeon places a tube called a cannula along the side of the Median Nerve. A special surgical instrument is inserted through the cannula that makes an incision in the Transverse Carpal Ligament. This surgery also opens the Carpal Tunnel and makes it larger to take pressure off of the Median Nerve. Because Endoscopic Carpal Tunnel Release spares some of the tissue in the palm, individuals may heal faster and experience less discomfort. 

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Recovery

Following surgery, your incision will be wrapped in a soft dressing. Your physician may recommend that you wear a splint to provide support and promote healing. You will be able to move your fingers immediately after surgery. You will need to avoid heavy grasping or pinching motions for about six weeks. Your doctor may recommend that you participate in occupational or physical therapy to gain strength, joint stability, and coordination. It may take several months for strength in the wrist and hand to return to normal.

Recovery from Carpal Tunnel Surgery is individualized and depends on the extent of the condition and the type of surgery performed. Your doctor will tell you what to expect.

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Prevention

There are several things that you can do that may help prevent the symptoms of Carpal Tunnel Syndrome. A general physical examination could identify medical conditions that are associated with Carpal Tunnel Syndrome. An early diagnosis may allow for optimal treatment.

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Introduction

Articular cartilage is a substance that covers the ends of many of your bones.  It cushions them during movement and provides a smooth surface for the bones in a joint to glide on.  The meniscal cartilages in the knee differ from articular cartilage, and function as stabilizers and shock absorbers.  Injury or certain medical conditions can cause the meniscal cartilage to tear. 

Cartilage tears cause joint pain, swelling, locking, giving way, and loss of function.  Arthroscopic surgery is commonly used to treat cartilage tears.  Arthroscopic surgery is associated with relatively minimal pain and short recovery periods.

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Anatomy

Cartilage covers the ends of many of your bones.  It forms a smooth surface for the bones in a joint to glide on during movement.  It acts as a shock absorber to cushion impacts.  The menisci are specialized cartilage structures in the knee that aid stability and act as shock absorbers.

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Causes

Cartilage in the knee and shoulder is especially vulnerable to tears from injury, particularly during sports. Arthritis can cause the cartilage to wear away. Chondromalacia is a term referring to cartilage softening and deterioration. Obesity puts extra stress on joints and can lead to cartilage tears, especially in the knees. Bone malalignments in the knee can contribute to uneven pressure and cartilage tears.

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Symptoms

A cartilage tear causes pain, swelling, and tenderness in a joint.  Your pain may increase with movement.  It may feel like your joint has a catch in it when you move it.  Your joint may not function as it did before.  A torn piece of cartilage may move abnormally within a joint.  It may prohibit movement and cause your joint to “give out,” particularly in the knee.

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Diagnosis

A doctor can diagnose a cartilage tear by reviewing your medical history, performing a physical examination, and viewing medical images.  You should tell your doctor about your symptoms, activities, and circumstances that lead to an injury.  Your doctor will perform a thorough examination of your joint. 

Your doctor will order X-rays to see the condition of your bones and identify arthritis.  Your doctor may order a magnetic resonance imaging (MRI) scan.  A MRI scan provides a very detailed picture of your joint, particularly showing the cartilage and ligaments.

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Treatment

Cartilage does not have a good blood supply and is not able to heal itself.  Tears cause the cartilage to deteriorate over time.  Consequently, most cartilage tears require surgery for treatment.

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Surgery

Arthroscopic surgery is commonly used to treat meniscal cartilage tears.  It allows surgeons to see, diagnose, and treat problems inside a joint.  Arthroscopic surgery uses an arthroscope and narrow surgical instruments that are inserted through small incisions.  An arthroscope contains a lens and lighting system that allow a surgeon to view inside of a joint.  The arthroscope is attached to a miniature camera.  The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.

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Recovery

Arthroscopy is less invasive than open surgical procedures.  It is associated with a decreased risk of infection, minimal bleeding, less pain, and a shorter recovery period.  Your doctor will let you know what to expect.

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Introduction

Clavicle fractures are a common orthopedic injury, especially among infants and young children.  The clavicle, known as the collarbone, is a long bone located at the top of the chest.  A clavicle fracture most frequently results from trauma.  The majority of clavicle fractures can heal without surgery.  If surgery is necessary, the bone is secured with surgical hardware, such as plates and screws.

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Anatomy

The clavicle is a long bone located on the upper chest.  It is part of the shoulder joint.  The clavicle provides stability for arm movements.  The clavicle is not fully developed (ossified) until the late teens or early 20s.

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Causes

Trauma is the main cause of clavicle fracture.  A forceful impact to the shoulder area during a motor vehicle collision, a fall, or sports can break the clavicle.  Newborns can experience a fractured clavicle as the result of a difficult birth. 

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Symptoms

You may hear a snapping sound and feel immediate pain when the clavicle breaks.  The pain may increase and become sharp with movement.  Bruising and swelling are common.  If the bone has moved out of position, it may appear as a bump under the skin.  Your shoulder area may not look as upright as usual.  It may appear slumped forward and downward.

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Diagnosis

You should contact your doctor immediately or go to the emergency department if you suspect you have broken your clavicle.  Your doctor will review your medical history and conduct a physical examination.  X-rays are taken to see the location and extent of the fracture.

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Treatment

Clavicle fractures are most commonly treated with slings or a figure eight splint.  A sling supports the arm and positions the shoulder to allow the fracture to heal.  A figure eight splint wraps around the front of the shoulders and crosses in the back.  It helps to maintain shoulder posture while the bone heals.  Over-the-counter or prescription medications are used for pain relief. You may participate in rehabilitation therapy to help regain strength and motion following splinting or surgery.

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Surgery

The majority of clavicle fractures can be treated without surgery.  However, opinions about surgery are ever changing.  Recent research shows that many patients that were not treated with surgery have had persistent problems.  Your doctor will discuss the benefits of both procedures with you.

Surgery may be needed for fractures that fail to heal, broken bones that come through the skin, or broken bones that are a threat to nearby nerves, blood vessels, soft tissues, or joints.  The surgery involves aligning the bone in the proper position and securing it in place with surgical hardware, such as screws and plates.  The surgical hardware may or may not be removed after the bone has healed.

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Recovery

Recovery from clavicle fracture is individualized and somewhat influenced by the age of the person.  Children may heal in three weeks, and adults may take four to six weeks to heal.  People can generally return to their full activity level in about 12 weeks.

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Introduction

Claw toe most frequently develops in older women.  It causes the joint at the base of the toe to bend upward and the other joints on the toe to bend downward in the shape of a claw.  Claw toe may be related to underlying medical conditions or caused from wearing poor fitting shoes.  It is important to diagnose and treat claw toe early because the condition tends to become worse over time.  Significant cases of claw toe may require surgery to correct the toe joints

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Anatomy

Your toes are part of your forefoot. They help you balance, walk, and move.  Your big toe (hallux) contains two bones (phalanges).  Your second through fifth toes contain three bones.  Claw toe results when the joint at the base of the toe is bent (contracted) upward and the remaining joints in the toe bend downward, creating the appearance of a curved claw.

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Causes

People may be born with claw toe or develop the condition later in life for a variety of reasons that are associated with structural changes in the nerves, muscles, or tendons that bend the toes.  Alcoholism, diabetes, multiple sclerosis, stroke, Charcot-Marie-Tooth disease, rheumatoid arthritis, spinal cord disorders, and cerebral palsy increase the risk of developing claw toe.  It can be an inherited condition for some people.  Wearing shoes that are too small or have high heels and pointed toes can contribute to claw toe.  In some cases, the cause of claw toe is unknown.

Claw toe is four to five times more common in women than in men.  The likelihood of claw toe increases with age.  It most frequently develops in adults that are in their 70s or 80s.

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Symptoms

Claw toe causes the joint at the base of the toe to bend upward and the remaining joints on the toe to bend downward, even to the point of curling under the foot.  The affected toe may be painful or irritated, especially at the base or tip of the toe.  Your toenail may be malformed.  Areas of thickened skin (corns) may develop on top of the toe and thickened skin (calluses) may appear on the ball of your foot.  It may be difficult to find a pair of shoes that is comfortable to wear.  Without treatment, claw toe tends to get worse over time, leads to a permanently deformed toe, and interferes with walking.

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Diagnosis

Your doctor can diagnose claw toe by reviewing your medical history and examining your foot.  X-rays will be taken.  In some cases, nerve studies may be conducted.

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Treatment

Treatments for claw toe depends on its cause and if the toe joints are flexible or rigid.  Although treating the underlying medical conditions is important to overall health, it usually does not reverse claw toe.  If your toe joints are still flexible, your doctor may recommend specific shoes, cushions, linings, and pads to help absorb force and place your toes in the proper position.  You should avoid wearing high heel narrow toed shoes.

Your doctor can safely remove corns and calluses.  You should not try to remove them at home.

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Surgery

Surgery may be necessary to correct the angle of rigid or fixed toe joints.  Surgery for claw toe is usually an outpatient procedure.  Surgery can entail lengthening or transferring tendons, removing cartilage at the end of bones, and using surgical hardware to hold the bones in position.  You may need to use crutches or a walker for a short time following surgery.

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Recovery

Recovery from claw toe surgery can take several weeks.  Fresh dressings are applied daily.  After about 2 weeks stitches are removed.  Surgical pins are removed after about two to four weeks.

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Prevention

You may help prevent claw toe by taking care of underlying medical conditions that can be treated.  Wearing low healed shoes with a roomy toe box can help.  Be sure to follow your doctor’s recommendations for using pads or special insoles.

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Introduction

Coccydynia is an uncommon painful condition that originates from the coccyx, the tailbone at the end of the spine.  Trauma and falls are the most frequent causes of coccydynia.  In the vast majority of cases, nonsurgical treatment, such as medications and physical therapy work well to ease symptoms.

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Anatomy

The spine is composed of a series of bones called vertebrae.  Joints that allow movement while providing stability connect the vertebrae.  The end of the spine, the coccyx, has 3-5 small bones.

The coccyx bones align in a curve like a small tail.  Some of the coccyx bones may be fused together.  However, fewer than 10% of people have a completely fused coccyx.

Muscles, ligaments, and tendons attach to the coccyx.  It plays a role in weight bearing when seated. 

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Causes

Coccydynia is caused by trauma to the coccyx, such as from a fall, injury during childbirth, or prolonged sitting.  Trauma can cause ligament inflammation or injure the coccyx where it attaches to the spine.  In some cases, the cause is unknown.

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Symptoms

The primary symptom of coccydynia is pain.  You may experience increased sensitivity to pressure, especially when sitting and leaning backwards.  The area around your tailbone may ache.  Coccydynia can cause pain that shoots down the legs.  It can also contribute to pain during sexual intercourse or bowel movements. 

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Diagnosis

A doctor can diagnose coccydynia by reviewing your medical history and examining you.  You should tell your doctor if you have fallen or given birth recently.  Imaging tests, such as X-ray or MRI, may be used to rule out other sources of pain.  Electromyography (EMG) and nerve conduction studies may be used to assess nerve function.

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Treatment

Coccydynia is typically first treated with non-steroidal anti-inflammatory medications.  Your doctor may recommend that you sit on a donut shaped pillow to help relieve tailbone pressure.  It may take several weeks or months for the pain to decrease.

For persistent or severe pain, your doctor may prescribe pain medications.  Local medication injections are used to place numbing and anti-inflammatory medications near the source (joint or bursa) of the pain.  Nerve blocks are used to interrupt a nerve’s ability to transmit pain signals.

Your doctor may gently move (manipulate) the coccyx after you receive a pain relieving injection.  You may be referred to physical therapy for gentle stretching.  Ultrasound therapy may be used, which soothes pain with warmth. 

If treatments fail to relieve symptoms, surgery may be used to remove a portion of the coccyx (coccygectomy).  The short outpatient surgery is successful for relieving symptoms for most people.  However, surgery is very rarely used. 

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Introduction

Complex regional pain syndrome (CRPS) is a type of chronic pain syndrome.  CRPS was formerly called reflex sympathetic dystrophy (RSD)and shoulder-hand syndrome.  CRPS causes severe burning pain and possible eventual deterioration of an affected arm or leg.  The cause of CRPS is unknown, but it can develop following an injury, stroke, or heart attack.  Prompt treatment is associated with the best outcomes.  If untreated, CPRS can cause irreversible extremity deterioration.

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Anatomy

The sympathetic nervous system is a part of the complex system that regulates involuntary bodily functions.  These are bodily functions that run automatically and are necessary for life.  Your sympathetic nervous system speeds up your heart rate, constricts your blood vessels, sends blood to your vital organs, raises your blood pressure, raises your blood sugar level, and increases sweating.  It energizes your body for immediate action in response to an emergency or “flight or fight” situation.

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Causes

The exact cause of CRPS is unknown.  Researchers suspect that changes in the sympathetic nervous system lead to poor regulation of blood flow, sensation, and temperature.  This contributes to problems involving the skin, nerves, blood vessels, bones, and muscles.  Another theory is that it may be related to an immune response.  CRPS can develop after an injury or infection in the arm or leg.  It can occur after heart attacks, cancer, nerve compression, and strokes.

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Symptoms

The symptoms of CRPS vary from person to person.  Severe burning pain, joint stiffness, and swelling are hallmark symptoms of CRPS.  It can affect an arm or leg.  Three stages characterize CRPS.  Not all people progress through all three of the stages.  Some people may stay in the first stage indefinitely, and others may skip a stage.

Stage I occurs at the onset of CRPS and can last about three months.  You may feel burning pain, stiffness, increased sweating, and warmth in your affected limb.  Your nails and hair may grow faster than usual.  Your skin may become dry, thin, and change color.

Stage II CRPS lasts from three to twelve months.  You may experience an increase in swelling.  Your skin may become cooler and more sensitive to touch.  Your pain may become more widespread.  Your joints and muscles may become stiffer.

Stage III occurs from one year on.  Changes in Stage III may be irreversible and permanent.  The pain may spread to your entire limb.  Your joints may be very stiff and very difficult to move.  You may experience muscle wasting and contractures.

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Diagnosis

Early diagnosis of CRPS is important for the best treatment results.  Your doctor can diagnose CRPS by reviewing your medical history and conducting a physical examination.  You should tell your doctor about your symptoms and their progression.  Your doctor will examine your limb for skin changes, swelling, changes in blood flow, and loss of mobility.  Your doctor may order tests such as X-rays, bone scans, or nerve studies.  There is no test, however, that can diagnose specifically CRPS.

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Treatment

To ensure the best outcome, it is important to start treatment as soon as possible.  Treatment for CRPS includes medications, rehabilitation therapy, injections and surgery.  There is no true cure for CRPS, but treatments in the early stages can prevent the disease from progressing, and cause them to regress.  Treatment goals during the advanced stages are aimed at symptom relief and improving function. 

Your doctor can prescribe medications to help ease your symptoms.  A combination of medications may be used including pain relievers, antidepressants, blood pressure medications, and steroids.  Injected pain relieving medications, spinal cord stimulation, and implanted medication delivery pumps may provide pain relief for longer periods of time.  Hand therapy can help ease your symptoms and regain function in your limb.

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Surgery

Surgery is rarely indicated for CRPS.  For those cases in which the syndrome is caused by nerve injury or compression, surgery to resolve the problem can help relieve symptoms.

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Recovery

CRPS that is treated in the early stages has the best outlook.  If treated early, CRPS can go into an inactive state and function is optimized.  If CRPS is not diagnosed and treated promptly, irreversible changes can occur in the involved extremity.

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Prevention

There is no known prevention for CRPS.  Prompt treatment may prevent the progression of symptoms.

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Introduction

Cubital Tunnel Syndrome is a condition caused by pressure on the ulnar nerve at the elbow.  Nerves carry messages between the brain, spinal cord, and body parts.  When a nerve is compressed, it cannot function properly.  Cubital Tunnel Syndrome is the second most common nerve entrapment syndrome, after Carpal Tunnel Syndrome. 
 
The Ulnar Nerve carries signals for sensation in one half of our ring finger and our small finger and to our muscles that perform fine hand movements.  Individuals with Cubital Tunnel Syndrome have difficulty handling objects and performing gripping motions.  Individuals may feel pain, numbness, and a “tingly” sensation, similar to when the “funny bone” is hit.  When the" funny bone " is hit, the odd feeling is actually caused by the Ulnar Nerve. 

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Anatomy

The Ulnar Nerve runs from the side of our neck, down our arm, and to our fingers.  The elbow is the most common site for Ulnar Nerve compression. At the elbow joint, the Ulnar Nerve passes through a passageway, formed by muscle, ligament, and bone, called the Cubital Tunnel at the inside part of the elbow. If the Ulnar Nerve is compressed at the Cubital Tunnel, it will send faulty messages as it travels down the forearm into the hand and fingers The Ulnar Nerve supplies the sense of feeling to the outer half of our ring finger and our little finger. The Ulnar Nerve also sends messages to some of the muscles that move our hands and fingers. These muscles are called the Interossei and the Adductor Pollicis. The Interossei muscles in the hand work to move our fingers together and apart. When the fingers and thumb spread open, the Adductor Pollicis moves the thumb back towards the hand. These hand and finger movements are especially important for manipulating and holding objects.

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Causes

Cubital Tunnel Syndrome can result from Ulnar Nerve compression. Its cause is unknown but several factors appear to contribute to it. Its most common cause appears to be from repeated elbow movements. The Flexor Carpi Ulnaris muscle can press on the Ulnar Nerve as it runs through the Cubital Tunnel. The Ulnar Nerve can also become irritated from pressure on the elbow. This can occur when the elbow is leaned on or pressed on for long periods of time. Elbow fractures, trauma, bone spurs, swelling, or cysts are additional factors that can cause Ulnar Nerve compression and lead to Cubital Tunnel Syndrome.

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Symptoms

Cubital Tunnel Syndrome frequently causes numbness and tingling in the ring finger and little finger.  Your symptoms may come and go.  They may happen more often when your elbow is bent, such as at night when sleeping in one position.  You may experience poor finger coordination and a weak grip.  This may interfere with activities such as holding objects in your hand, using a keyboard, or playing an instrument.  If the Ulnar Nerve compression is not treated it can cause muscle deterioration and lead to permanent impairment.  You should always contact your physician if the symptoms of Ulnar Nerve compression last more than a few weeks and interfere with normal activity.

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Diagnosis

You doctor will perform an examination and review your medical and activity history to make a diagnosis of Cubital Tunnel Syndrome.  Your physician will attempt to find where the Ulnar Nerve is compressed and will examine your forearm, elbow, hand strength and movement.  Your doctor may tap on your Ulnar Nerve in the cubital tunnel to see if it reacts and will test for sensation.  The examination may cause a bit of discomfort as the physician is looking for the cause of the symptoms.
 
Your doctor may use imaging tests to identify structural factors, such as bone spurs or arthritis, which may contribute to nerve compression.  These tests can include X-rays, Computed Tomography (CT scans), or Magnetic Resonance Imaging (MRI).  An X-ray uses a camera to take a picture of the elbow area to show the bone’s condition.  CT scans take pictures in layers, so it produces images in the form of slices that make up the elbow, like the slices that make up a loaf of bread.  MRI scans provide a very detailed view of the elbow complex.  Like the other imaging tests, the MRI equipment focuses on the area to be examined and takes pictures.  All of these imaging tests are painless and require that you remain very still.
 
In some cases, the physician may use nerve conduction studies to measure how well the Ulnar Nerve works and to help specify the site of compression.  Electromyography (EMG) is usually performed with nerve conduction studies.  This test examines the nerve’s input into the muscles.  The test may feel uncomfortable, but only during the actual test then resolves quickly.

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Treatment

Most cases of Cubital Tunnel Syndrome respond to non-surgical treatments.  Treatment typically includes activity restriction, rest, and pain relief.  You should avoid repetitive elbow movements and avoid leaning or putting pressure on the elbow.  In other words, you should refrain from the movements and postures that cause discomfort.  You should take frequent breaks to rest when performing such movements.  Elbow splints may be worn to keep your arm straight, especially while sleeping.  Anti-inflammatory medications may provide pain relief.

Some physicians prescribe occupational or physical therapy.  The occupational or physical therapists focus on gentle exercises to help the Ulnar Nerve slide through the Cubital Tunnel.  The exercises may help keep the forearm and wrist muscles healthy while preventing joints from becoming stiff.

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Surgery

Your doctor may recommend surgery for you if you do not receive relief from non-surgical treatments.  Surgery can remove pressure from the Ulnar Nerve and prevent further damage. Your surgeon may also recommend surgery if you have muscle wasting.  
 
The surgery may be done as an outpatient procedure or may require an overnight stay at the hospital.  You may be sedated for surgery or remain alert with a regional anesthesia that blocks the feeling in your arm.

The surgeon has various options for relieving the pressure on the Ulnar Nerve.  In one procedure, the “roof” is removed from the Cubital Tunnel.  This method is called simple decompression.  The most common surgical procedure is called an Anterior Transposition of the Ulnar Nerve.  In this procedure, the surgeon makes an incision at the elbow and moves the Ulnar Nerve from behind the elbow to a new place in front of the elbow.  If the Ulnar Nerve is relocated under the skin and fat but on top of the muscle, the procedure is called a Subcutaneous Transposition of the Ulnar Nerve.  When the Ulnar Nerve is placed under the muscle it is called a Submuscular Transposition of the Ulnar Nerve.  
 
The surgeon considers many factors when selecting which method to use and will discuss the appropriateness of each with you.
 
Following surgery, a splint is typically worn on the elbow for a few weeks.  Individuals who receive a Submuscular Transposition of the Ulnar Nerve may need to wear a splint for a longer time, from three to six weeks.  Occupational or physical therapy is recommended to regain strength and motion in the arm. 

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Recovery

If you require surgery for Cubital Tunnel Syndrome it may take several months to recover, but generally you can achieve good results.  Individuals with muscle or nerve damage may take a longer time to recover.  Nerves take a long time to heal.  Nerves regenerate at about one millimeter a day. For individuals with severe nerve or muscle damage, complete healing may not be possible, and they may have some symptoms even after surgery.

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Introduction

Foot problems are a common complication of Diabetes. Diabetes is a disease that affects how the body uses glucose, a sugar that is a source of fuel for the body. Normally, insulin, a hormone, helps glucose get into the body cells so that it is used for energy. People with diabetes either do not produce enough insulin or the insulin does not work like it should. Therefore, glucose does not get into the body cells. As a result, there is too much sugar in the blood, which can make people ill and result in medical complications. Diabetes is manageable. People with diabetes need to be aware of the possible associated medical problems.

Diabetes-related foot problems are most frequently caused by nerve damage and poor blood circulation. Infections, ulcers or sores, deformities, and trauma can all be the result. Foot problems are the leading reason for diabetes-related hospitalization. Further, diabetes is the leading cause of lower leg and foot amputation. Technology, research, and most importantly, diligence by individuals with diabetes can greatly improve the management of diabetes and reduce the risk of foot complications.

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Anatomy

Your foot is a complex structure. It contains 28 bones that form 25 joints. The foot is divided into three regions: the forefoot, midfoot, and hindfoot. The hindfoot contains your calcaneus bone or heel. The forefoot contains your toes. Your toes are composed of small bones called phalanges. Your forefoot and midfoot bones, along with muscles and ligaments, form the arches in your foot. 

Arches are important for absorbing shock and balancing your body. Your forefoot is a source of mobility. You push off the ground with your forefoot whenever you take a step. Your foot also bears the weight of your body and provides a base of support.

Nerves transmit impulses or messages between your foot and brain about sensation, positioning, and movement. Your circulatory system supplies blood to keep your foot structures healthy. Like the rest of your body, your feet are covered with skin. The skin on the sole or bottom of your foot is thicker than the skin on the dorsal or upper side of your foot.

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Causes

The feet are very vulnerable to diabetes-related complications. Further, there are a variety of foot problems that can occur. Diabetes-related foot conditions are most frequently caused by poor blood circulation, infection, and nerve damage that can result in ulcers or sores, deformities, and trauma.

Diabetes can often lead to nerve damage called peripheral neuropathy. Peripheral neuropathy is a condition in which nerve function deteriorates in the limbs. This leads to a gradual loss of feeling in the hands, arms, legs, and feet. This is often problematic because pain is what enables you to know when something is wrong. Without pain, you may not realize that you have bruises, cuts, blisters or burns and seek medical treatment. It is important that people with diabetes receive medical treatment for foot sores because diabetes-related circulation problems can lead to more problems.

Peripheral vascular disease is a common diabetes-related circulation disorder. Poor circulation results in reduced blood flow to the feet. It can restrict the delivery of oxygen and nutrients that are required for normal wound maintenance and repair. As a result, foot injuries, infections, and ulcers may heal slowly or poorly. Minor skin problems on the feet can become worse and lead to infection.

People with diabetes are generally more prone to infections than people without diabetes. Wounds and injuries can be difficult to heal if diabetes is uncontrolled. This can be especially true of wounds in the feet. Infections tend to get worse or remain undetected, especially in the presence of diabetic neuropathy or vascular disease. Neuropathy can cause you to be unaware of wounds. Additionally, the increased pressure from the feet carrying the body weight aggravates foot wounds. Further, shoes can cause skin friction, rubbing, and tearing. The hot moist environment of shoes is favorable to infection and foot ulcers. Foot ulcers are sores caused by skin breakdown exacerbated by infection. Foot ulcers tend to develop over areas of high pressure, such as bony prominences or foot deformities. 

Foot deformities are another common problem associated with diabetes. They occur when the ligaments and muscles that stabilize the foot bones deteriorate. This can cause the bones to shift out of position or for a series of bones that make up an arch to collapse. A hammertoe deformity is a common condition that occurs most frequently in the second toe, although it can be present in more than one toe. Increased pressure on the tips of the phalanges and the lack of muscle stability causes a joint in the toe to become permanently flexed with a claw-like appearance. The toe deformity and pressure displacement makes the toe susceptible to skin ulcers.

Charcot foot is another common foot deformity associated with diabetic neurogenic arthropathy. Neurogenic arthropathy is a progressive degenerative arthritis that results from nerve damage. Charcot foot most frequently affects the metatarsal and tarsal bones located in the midfoot and forefoot.

Charcot foot causes the foot muscles, ligaments, and joints to degenerate or break down. Without support, the foot becomes deformed. Without joint stability, the foot becomes unstable making walking difficult. Inflammation and pressure eventually can cause bone dislocation. The arches in the foot can collapse creating a rocker-bottom appearance. 

People with Charcot foot have impaired or absent abilities to feel pain, temperature, and trauma. They may not be able to sense the position that their foot is in. This makes them vulnerable to injury, such as fractures, sprains, joint dislocation, bone erosion, cartilage damage, and foot deformity. They may even continue to walk on a broken bone without knowing it, because they cannot feel it.

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Diagnosis

Your doctor can diagnose diabetic foot problems with a physical examination. Your doctor will ask you about your symptoms. There are a variety of tests your doctor may use to diagnose a problem with your foot. Testing is individualized depending on your symptoms and examination findings. Some of the most common assessments are described below.

Non-invasive vascular tests can provide information about the blood circulation in your feet. Your doctor can measure the amount of oxygen in your blood with a transcutaneous oxygen measurement. Your doctor will simply place sticky patches on your skin for this assessment. The blood pressure in your arm and ankle can be compared using the ankle-brachial index (ABI). 

Another common assessment used during a foot exam is sensitivity testing. Nylon monofilament testing is useful to determine the degree of sensation in your foot. The test does not hurt. Your doctor will simply place the tip of a very thin piece of nylon, similar to a plastic thread, against the skin of your foot. Your doctor will test your foot in various places and alter the thickness of the filament. You will tell your doctor when you feel the filament touch your skin. A similar procedure using wands of random temperatures can be used to determine to what degree you can feel hot or cold temperatures. 

In most cases, imaging tests are ordered to identify fractures, degeneration, and deformities. An X-ray may be ordered to show the type and location of your fracture. Some fractures, such as stress fractures, may not show up on an X-ray. In such cases, Computed Tomography (CT) scans or Magnetic Resonance Imaging (MRI) scans may be used to take a more detailed look at your bones. X-rays, CT scans, and MRI scans are painless procedures.

Your doctor may order an angiography to see the condition of the blood vessels in the legs and feet. An angiogram is a type of X-ray for the blood vessels. You will receive a small harmless injection of a radioactive substance that will highlight the blood vessels on the X-ray image.

A bone scan is useful for identifying bone abnormalities that are often associated with diabetes. A bone scan may show fractures, tumors, infection, and bone deterioration. A bone scan requires that you receive a small harmless injection of a radioactive substance. The substance collects in areas where the bone is breaking down or repairing. Further, three-phase bone scans and radiolabeled leukocyte scans are tests for determining the presence of infection.

Wound classification is very important for the treatment of diabetic-related ulcers. If you have an ulcer, your doctor will grade its progression with a diabetic foot or wound classification system. A wound is classified based on its stage of formation, from being visible on the skin to penetrating through the skin and to the bone. Additionally, your doctor may order sensitivity testing and wound cultures to identify or rule out infection. 

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Treatment

Overall, people with diabetes must monitor their blood glucose levels carefully, eat a balanced diet, exercise regularly, and see a physician routinely to prevent and stay on top of any problems that might develop. There are several options for diabetes-related foot problems. Treatment is individualized. It will depend on the source and severity of your foot problem. Your doctor will discuss appropriate treatment options with you.

Non-surgical treatments for diabetes-related foot problems include splinting, casting, or bracing to correct bone deformities. Your doctor can recommend proper footwear to provide structure and improve blood circulation. This may include a custom-walking boot. Your doctor can also provide medications or treatments for infections and skin ulcers.

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Surgery

The main goal of treatment is to improve the integrity of the foot and reduce the risk of surgery and amputation. Surgery is considered for deformities that are too severe for a brace or shoe. Surgery may also be required to resolve advanced skin ulcers. In extreme cases, surgical amputation of the toes, foot, or leg is required to prevent further health problems and protect the remaining limb.

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Recovery

Recovery from diabetes-related foot problems is different for everyone. It depends on the type of problem you experienced and the type of treatment you received. Because diabetes-related foot problems can be progressive, it is extremely important that you reduce your risk of complications and amputation by following preventive measures.

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Prevention

The following are tips to help prevent diabetes-related foot problems:
• Monitor your blood glucose levels carefully, eat a balanced diet, and exercise regularly. See a physician regularly to prevent and stay on top of any problems that might develop. 
• Inspect your feet daily. Examine your feet for redness, warmth, blisters, ulcers, scratches, cuts, and nail problems. Feel for hard or dry skin. Look at the bottoms of your feet and between your toes. Use a mirror or have someone else look for you to check the bottom of your feet for redness or cracking. 
• Examine the inside of your shoes for foreign objects, protruding nails, and rough spots before putting them on. 
• Have custom-molded orthotics or shoes made by a foot specialist. The special footwear can help prevent ulcerations and infections in the feet.
• Buy shoes late in the day and never buy shoes that need "breaking in." Shoes should be comfortable the minute you put them on. Select shoes with deep toe boxes and made of leather upper material. Do not wear new shoes for more than two hours at a time and do not wear the same shoes every day.
• Contact your foot doctor immediately if you experience ANY injury to your foot or if you notice any changes in your feet. Even a minor injury is important for a person with diabetes. 
• Do not file down, shave or remove calluses or corns yourself. This should ONLY be done by a foot specialist.
• DO NOT SMOKE! It decreases the blood supply to your feet. • Ask your doctor about precautions for soaking your feet.
• Do not trim your own toenails. Your foot specialist should do this.
• Do not use any strong antiseptic solutions on your feet. Iodine, salicylic acid, and corn or callus removers can be dangerous.
• Do not wear socks or stockings with tight elastic backs and never use garters. Do not wear any socks with holes and always wear shoes with socks.
• You should never use any type of sticky product such as tape or corn plasters on your feet. They can tear your skin.
• In the winter, wear warm socks and protective footwear. Avoid getting your feet wet in the snow and rain and avoid letting your toes get cold.
• Keep feet away from heat--hot water bottles, heating blankets, radiators, and heating pads. Burns can occur without your knowledge. Water temperature should always be less than 92 degrees. Estimate the water temperature with your elbow or bath thermometer.
• Lubricate your entire foot if your skin is dry but avoid putting cream between your toes. 
• NEVER walk barefoot.

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Introduction

Dupuytren’s disease causes an abnormal thickening of the tissues located underneath the skin in the palm of the hand. As the tissue thickens it can form lumps and strong cords. The abnormal growth causes the fingers to bend in towards the palm of the hand.  Severe symptoms can cause contractures and loss of hand function. Dupuytren’s disease generally progresses slowly, but progression is unpredictable.

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Anatomy

The palm of your hand contains ligaments and tendons.  Ligaments are strong bands of tissues that connect your bones together.  Tendons attach muscles to bone.  The tendons in the palm of your hand flex or bend your fingers inward.  Your ligaments and tendons are covered and kept in place by the palmar fascia, a thin sheet of connective tissue.  The palmar fascia is located just beneath your skin.

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Causes

The cause of Dupuytren’s disease is unknown.  It may be associated with abnormal biochemical processes in the palmar fascia.  It is more common in people of Northern European descent.  It occurs more frequently in men than in women.  Dupuytren’s disease is rare among young people and more common in people over 40 years old.  If it occurs in young people, the condition tends to be very severe and quickly progressing.

Smoking and drinking alcohol increase the risk of Dupuytren’s disease.  Certain medical conditions are associated with an increased risk of Dupuytren’s disease.  Such conditions include diabetes, thyroid problems, epilepsy, pulmonary tuberculosis, and liver disease.

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Symptoms

The onset of Dupuytren’s disease is very slow.  Both hands may be affected but usually one hand is more affected than the other.  You may notice a small tender lump in the palm of your hand.  The tenderness will go away as Dupuytren’s disease typically is not painful.  Over time, tough cords may form beneath your skin.  The thickened tissue may cause your fingers to bend inward toward your palm.  Your ring finger and little finger are affected most often.  You may have difficulty straightening your fingers. 

The progression of Dupuytren’s disease is unpredictable.  For some, the condition may consist of a lump or thickening of the tissue.  Other people may experience severe symptoms, including contractures and loss of hand function.

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Diagnosis

Your doctor can diagnose Dupuytren’s disease by examining your hand.  You should tell your doctor about any symptoms and if they restrict the use of your hand.  Your doctor will look at and feel the skin on the palm of your hand for thickened tissue or nodules.  Your doctor will observe your finger positioning and test the movement of your finger joints.  You may be asked to perform the Table Top Test, in which you will attempt to place your open hand on a surface and flatten your palm and fingers out as far as you can.  This will be difficult in the presence of finger contractures.

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Treatment

There is no way to stop the progression of Dupuytren’s disease.  Your doctor will monitor the progress of your disease.  Injections may help relieve the pain in a lump that has formed early in the disease process.  Surgery is recommended if the fingers become flexed enough to interfere with the functional use of your hand.

Injectable enzymes to dissolve the diseased tissue were FDA approved in 2010. The product is called Xiaflex. Studies and ongoing use of the enzyme have shown success in treating finger contractures caused by Dupuytrens Disease.

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Surgery

The goal of surgery is to increase the movement of your fingers and restore their correct positions to improve hand functioning.  There are several different options for this.  Your surgeon may simply divide the thickened bands in a procedure called fasciotomy.  Your surgeon may remove the sheet of diseased palmar fascia in a procedure called fasciectomy.  In some cases, a skin graft may be necessary.

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Recovery

Following surgery, you will participate in rehabilitation with a hand therapist who will instruct you in strengthening and stretching exercises.  You may receive therapy treatments to reduce swelling and ease pain.  Your hand therapist will provide you with a splint to position your hand and promote healing.

Surgery is not always a permanent solution for Dupuytren’s Disease.  The condition tends to gradually recur over time.  

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Introduction

Epidural injections are a non-surgical treatment option for low back (lumbar) pain and pain radiating into the legs.  The procedure involves delivering pain relieving medications directly to or near the source of the pain in the spine during a short outpatient procedure.  Epidural injections can be very effective for some people and may be repeated over time.  For some, physical rehabilitation is possible once the pain has been relieved.

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Anatomy

The lumbar area of your spine is located in your lower back and forms the curve below your waist.  Five large bones (vertebrae) make up the lumbar spine.  A disc between each bone allows movement and acts as a shock absorber.  The opening in the center of each bone forms the spinal canal. 

Your spinal cord is located within the protective spinal canal.  The spinal cord extends from the brain and is a major part of your nervous system.  The spinal cord does not fill the entire space in the spinal canal.  Instead, the spinal cord is surrounded by the epidural space (cavity), which contains tissue, nerves, and blood vessels.

Spinal nerves extending from the spinal cord travel out of the lumbar spine to the lower back, buttocks, legs, and feet.  The spinal cord and nerves at the lumbar spine level send signals for sensation and movement between your brain and lower body muscles.  The spinal cord tapers near the first lumbar vertebra and forms a group of nerves called the cauda equina.  The cauda equina is involved with regulating bowel and bladder functions.

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Causes

Lumbar epidural injections are used to treat pain from ruptured discs, cysts, arthritis, fractures, cancer, shingles (post herpetic neuralgia) or other changes in the spine that cause nerve irritation and pain.  Spinal stenosis is a condition that causes the spinal canal to narrow and put pressure on the spinal cord and nerves.  Compressed, pinched, or irritated nerves in the lumbar spine can cause sciatica.  This condition causes pain that can extend from the low back, through the buttocks and legs, and down to the feet. In addition, lumbar epidurals are used to treat cancer-related pain.

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Symptoms

The type of symptoms that you experience depends on the cause of your low back pain.  Your pain may spread (radicular pain) to your buttocks, legs, and feet.  You may experience stiffness, weakness, numbness, or tingling.  If you experience a loss of bowel or bladder control, you should seek medical attention immediately.

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Diagnosis

Your doctor will examine you and conduct tests to determine the cause of your low back pain.  Imaging tests, lab tests, and nerve studies may be used to provide your doctor with more information.  Your doctor will let you know if epidural injections are a treatment option for you.

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Treatment

Epidural injections administer local anesthetic and/or steroids into the epidural space.  Steroid medication is used to reduce swelling and inflammation.  A salt water (saline) solution may be added to flush chemicals that cause inflammation. Short or long acting anesthetic medications are used to relieve pain.  The various pain syndromes include lumbar radiculopathy, spinal stenosis, arthritis, cancer related pain and neuropathy.

Epidural injections are short outpatient procedures that can be given at a surgery center, hospital, or your doctor’s clinic.  You will wear a gown for the procedure.  You will be positioned sitting up or lying on your side or stomach.  Before you receive the epidural injection, your lower back area will be sterilized, and numbed with an anesthetic.  You may receive a relaxing medication before your procedure begins.

Your doctor will use a live X-ray image (fluoroscopy) to carefully insert and guide the needle to the epidural space.  A contrast dye is used to confirm the needle placement.  A hypoallergenic dye is necessary for patients with allergies to shellfish or iodine dye.  Next, the medication solution is delivered to the epidural space, and the needle is removed.

You will be monitored for several minutes before you can return home.  Your doctor will instruct you on how to relieve temporary mild pain at the injection site.  Most people can resume their regular activities the next day.

Introduction

An extensor tendon injury occurs when the tendon is torn, cut or otherwise detached.  The extensor tendons attach to the back of your fingers and thumbs.  They allow your fingers and thumbs to straighten and perform fine coordinated movements.  Extensor tendon injuries can result from trauma, burns, or arthritis.

Extensor tendon injuries cause loss of movement, pain, and swelling.  Some extensor tendon injuries are treated with splinting and hand therapy.  Surgery may be necessary in cases of tendon separation, fracture, or malalignment.

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Anatomy

Your hand is composed of many bones that provide structure for your wrist and fingers.  Your fingers and thumbs are made up of bones called phalanges.  The bones are connected with strong ligament tissues.  Tendons are strong fibers that attach your muscles to your bones and allow movement.  Your hand also contains nerves, blood vessels, and fat.  The skin that covers your hand protects it from the environment.
 
Your extensor tendons begin in your forearm and continue to the back side of your fingers and thumb.  As the extensor tendons reach your fingers, they become flat and thin.  They are located just underneath the skin.  The extensor tendons are attached to your phalanges via a complex system.  The extensor tendons allow your fingers and thumbs to straighten and perform fine coordinated movements.  

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Causes

Arthritis, burns, and injuries, such as cuts or jammed fingers, can cause extensor tendon injury.  Boutonniere deformities and mallet finger injuries are specific types of extensor tendon injuries.  An extensor tendon may be partially or completely cut.  It can remain intact but pull a piece of bone away from where it attaches on the phalanx.  This is called an avulsion fracture.

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Symptoms

An extensor tendon injury can cause your finger or hand to feel painful and swollen.  It may be difficult or impossible for you to extend your finger. 

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Diagnosis

Your doctor can diagnose an extensor tendon injury by reviewing your medical history and examining your hand.  X-rays can identify an avulsion fracture or joint malalignment.

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Treatment

Many factors affect the seriousness of an extensor tendon injury such as associated fractures, infection, the degree of tendon separation, and if the tendon was cut or torn.  Treatment is individualized and your doctor will discuss your options with you.  Nonsurgical treatments for extensor tendon injuries include splinting and hand therapy.

Splinting positions your finger to allow the extensor tendon to heal.  It is important not to remove the finger splint at anytime, even while you shower.  If the finger splint is removed, even for the shortest amount of time, the treatment is disrupted and the process must start all over.  You will wear your splint for several weeks full-time, followed by a part-time splint schedule.  A dynamic splint may be used to allow movement while protecting the healing tendon.

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Recovery

Splinting and surgical treatments are usually followed by hand therapy.  A hand therapist will show you exercises to stretch and strengthen your joints.  The other joints in your fingers may become stiff and benefit from hand therapy as well.  It can take an extensor tendon injury several months to recover from completely.  Healing is an individualized process.  Your doctor will let you know what to expect.

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Introduction

The bone in your thigh is called the femur.  It is the strongest bone in the body.  The femur is very difficult to break or fracture, but it can, as the result of a high impact vehicle crash or fall from a great height.  Treatment for a femur fracturedepends on the location and type of break in the bone, as well as the age of the person. 

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Anatomy

The femur is the long bone in your thigh.  The long part of the bone is called the shaft.  The top of the femur (femoral head) is part of the hip joint.  The lower part of the femur helps form the knee joint. 

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Causes

Femur fractures result from high impact forces, such as those experienced in a high-speed vehicle collision or fall from a height.  Older adults may experience femur fractures near the hip or the knee side of the bone after a fall, as the result of osteoporosis, a degenerative bone disease.

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Symptoms

Femur fractures can cause severe pain, swelling, and bruising.  Your leg may look shorter or out of its normal position.  You may not be able to move your leg.

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Diagnosis

Your doctor can diagnose a femur fracture by examining your leg and taking some X-rays.  X-rays of the pelvis and knee joints may be taken as well.  Your doctor will evaluate the nerves and blood vessels in your limb.

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Treatment

Casting may be used to treat young children with a fracture in the shaft of the femur.  A spica cast is used to immobilize the hips and the other leg.

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Surgery

Most femur fractures are treated with a surgical procedure called intramedullary fixation.  The procedure entails inserting a rod (intramedullary nail) into the center of the bone.  The rod is secured with surgical screws.  The rod provides support and stability while the fracture heals.  After the fracture has healed, the hardware serves no further purpose, and may be removed.

Other less commonly performed femur surgeries include plating and external fixation.  Plating involves securing a plate and screws into the bone to keep it in proper position while it heals.  External fixation uses a frame that is aligned on the outside of the leg and secured with surgical pins to keep the bones from moving while they heal.  External fixation may be used in the case of severe skin wounds and a femur fracture.

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Recovery

Physical therapy rehabilitation usually follows treatment.  You will learn exercises to increase range of motion, flexibility, and strength.  People that receive intramedullary fixation may be able to bear weight and walk sooner than people may with other types of treatments. 

Overall, recovery is different for everyone.  Recovery time depends on several factors, including the severity and location of injury, if nerves or blood vessels were affected, and the type of treatment that you received.  It can take a femur fracture from three to six months to heal.

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Introduction

Fibromyalgia is a chronic condition that causes widespread pain and tender points on muscles.  Although the exact cause of fibromyalgia is unknown, there appear to be several factors that may contribute to it.  In addition to lifestyle changes and physical therapy, recently FDA approved medications appear to ease the symptoms of fibromyalgia for some people.

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Anatomy

Fibromyalgia is distinguished by pain and tender points on both sides and the upper and lower portions of the body.  There are 18 tender point locations including areas at the back of the head, upper back and shoulders, neck and upper chest, elbows, hips, and knees.  When pressure is applied to the muscles and tissues at these locations, pain is felt. 

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Causes

The exact cause of fibromyalgia is unknown.  Researchers have many theories including hereditary factors, physical and emotional stress, sleep quality, nervous system sensitivity, brain functioning, infection, and a combination of factors.  Although weather changes and physical activity appear to influence fibromyalgia, there are no known triggering causes.

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Symptoms

Fibromyalgia causes widespread pain that seems to originate from muscles.  The pain may be deep, dull, shooting, or burning.  The degree of pain may range from minor to severe.  For some people, the pain is more bothersome in the evening than it is during the day.  Stress, physical activity, and weather changes may cause an increase in fibromyalgia symptoms.

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Diagnosis

There is no specific test for fibromyalgia.  It is considered a "diagnosis of exclusion," meaning all other causes of the symptoms should be ruled out.  A doctor can diagnose fibromyalgia by reviewing your medical history, examining you, and considering your list of symptoms.  It is helpful to bring a written list of symptoms to your appointment. 

Your doctor may conduct blood tests to rule out other conditions with similar symptoms.  A diagnosis of fibromyalgia requires pain or tenderness reported at a minimum of 11 tender point locations with symptoms that have lasted for 3 months or longer.

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Treatment

Relaxation and lifestyles changes can make symptoms of mild fibromyalgia better.  Your doctor may recommend physical therapy, patient education, support groups, and counseling.  Regular exercise, pacing activities throughout the day, eating a balanced diet, and good sleep habits can help as well.

In recent years, researchers have made several breakthroughs with prescription medications to ease symptoms of fibromyalgia.  Low doses of certain antidepressant medications and anti-inflammatory medications appear to help certain people.  Since 2007, the Federal Drug Administration (FDA) has approved the prescription medications Lyrica, Cymbalta, and Savella for the treatment of fibromyalgia, and more studies are underway.

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Am I at Risk

Fibromyalgia develops most frequently in people between the ages of 20 and 50, although it can occur at any age, including during childhood.  The risk of developing fibromyalgia appears to increase with age.  Fibromyalgia occurs more often in women than in men.  People with fibromyalgia have a tendency to have other conditions as well, such as chronic fatigue syndrome, depression, endometriosis, headaches, irritable bowel syndrome (IBS), lupus, osteoarthritis, post-traumatic stress disorder (PTSD), restless leg syndrome, sleep apnea, and rheumatoid arthritis.

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Introduction

A flexor tendon injury occurs when the tendon is cut or ruptures.  The flexor tendons attached at the palm side of your fingers and thumbs.  They allow your finger and thumb joints to bend, grasp items, and perform fine coordinated movements.  The muscles that control these tendons are in the forearm.  Lacerations, other trauma, and rheumatoid arthritis are the primary causes of flexor tendon injuries.

Flexor tendon injuries can cause loss of movement, pain, and swelling.  Flexor tendon injuries require surgical repair.  Splinting and hand therapy rehabilitation usually follow surgical treatment.

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Anatomy

Your hand is composed of many bones that provide structure for your wrist and fingers.  Your fingers and thumbs are made up of bones called phalanges.  The bones are connected with strong ligament tissues.  Tendons are strong fibers that attach your muscles to your bones and allow movement.  Your hand also contains nerves, blood vessels, and fat.

Your flexor tendons begin in your forearm and continue to the palm side of your fingers and thumb.  Each finger has two flexor tendons and your thumb has one.  They are located just underneath the skin.  Sheaths thickened in areas by fibrous pulleys guide the flexor tendons and keep them close to your phalanges during motion.  The flexor tendons allow your fingers and thumbs to bend, grasp items, and perform fine coordinated movements.  The nerves in your fingers (digital nerves) travel parallel and along both sides of the flexor tendons.

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Causes

Deep cuts are the main cause of flexor tendon injuries.  They may also occur during sports, such as football, wrestling, rugby, and rock climbing.  Rheumatoid arthritis can cause flexor tendons to rupture.  The outward injury often appears simple, but is usually complex when involving the tendons and possibly the nerves.

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Symptoms

A flexor tendon injury can cause your finger joints to feel painful and swollen.  It may be difficult or impossible for you to move your finger.  You may not be able to bend your finger joints.  Nerves are located very close to the flexor tendon.  If the nerves are injured, your finger may feel numb.

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Diagnosis

Your doctor can diagnose a flexor tendon injury by reviewing your medical history and examining your wrist, hand and fingers.  You should tell your doctor if you sustained an injury.  Your doctor will carefully move your finger joints.  Your doctor will test the sensation and blood flow to your fingers.  X-rays can identify bone injuries. 

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Treatment

Flexor tendon injuries do not heal well without surgical repair.  When a flexor tendon separates, the two pieces pull away from each other, making it impossible for the tendon to heal without surgery.

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Surgery

There are many ways to surgically repair flexor tendons.  Certain types of injuries need specific types of surgery.  Your hand surgeon will stitch the ends of the tendon together and repair damaged nerves, blood vessels, or bones.  A splint will immobilize your hand to allow the flexor tendon to heal after surgery.

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Recovery

Hand therapy rehabilitation and continued splinting follow flexor tendon repair surgery.  Hand therapy will help you regain strength, flexibility, motion, and functional use of your hand.  Recovery from flexor tendon surgery is very individualized and rarely is full normal motion regained.  Therapy protocols vary and will depend on the nature of your injury and repair.  Splint protection is generally required for six weeks. Healing continues for three months after repair.  Your doctor will let you know what to expect.

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Introduction

Bones are the hardest tissues in your body. Although bones are strong, they can split or break under too much pressure or force. A broken bone is called a fracture. Fractures can occur in a variety of ways. The most common causes of fractures are injuries, prolonged stress from overuse, and bone weakening diseases, such as Osteoporosis or tumors. 

There are many types of fractures. They can range from a hairline crack to a bone that has broken into several pieces. Simple fractures may only require casting or splinting treatments. More complex fractures may need surgical intervention to align the bones for proper healing.

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Anatomy

As an adult, you have over 200 bones in your body. Your bones vary in size and shape. For instance, your arms and legs contain long bones. A series of small bones, called vertebrae, make up your spine. Very small bones form your hands and feet. Some of your bones have curves, including your ribs and skull. All of your bones line up and connect to form your skeleton. In addition to creating your body structure, your bones produce blood cells, form joints with muscles for movement, and protect your internal organs. 

Your bones are live tissues. They change and grow like the other parts of your body. Most of the bones in your body are composed of the same layered materials. 

The outer layer of a bone is called the periosteum. It is considered the life support system for the bone because it provides the nutrient blood for bone cells. The periosteum also produces bone-developing cells during growth or after a fracture. Underneath the periosteum is compact bone, known as the cortex. Compact bone is solid and hard. It covers the cancellous “spongy” bone. The cancellous bone looks like a sponge because it contains many pores. It can resist the stresses of weight, postural changes, and growth. In many bones, the cancellous bone contains or protects the red marrow or bone marrow. Red marrow contains developing and mature blood cells.

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Causes

The most frequent causes of fractures are falls and motor vehicle crashes. There is a higher incidence of fractures in some sports that involve prolonged impact, high impact, balance, or high speeds. Stress fractures can result from prolonged impact or repetitive forces. For example, running or jogging can cause stress fractures in the leg, foot, ankle, or hip. High impacts can occur during contact sports, including tackles in football or punches in boxing. Skateboarding, bicycle riding, and snow skiing are sports that involve balance and speed. Fractures can occur during contact with a hard surface, for instance during a fall to the cement while skateboarding or during contact with an object, such as a tree while snow skiing. 

Fractures can also be the result of physical violence. Fractures can result from a blow with a fist or kick, or from contact with a solid weapon, such as a bat. 

Although the majority of fractures result from motor vehicle crashes and falls, some fractures occur because of diseases. Osteoporosis is a medical condition that causes more bone calcium to be absorbed than is replaced. Calcium is necessary for hard, healthy bones. Osteoporosis causes a reduction in bone density and brittle or fragile bones that are vulnerable to fractures. Type I Osteoporosis usually affects women between the ages of 51 and 75. Type I Osteoporosis is associated with spine and wrist fractures. Type II Osteoporosis usually affects people between the ages of 70 and 85. Type II Osteoporosis is associated with hip, pelvis, arm, and leg fractures. 

Bone tumors are another disease-related cause of fractures. Most bone tumors originate elsewhere in the body and metastasize or spread to the bone. Very rarely do cancerous tumors begin in the bone. Tumors can weaken bones making them susceptible to fractures.

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Symptoms

In some cases, a snap or cracking sound may be heard when a bone fractures. You may feel sharp, deep, or intense pain along with numbness or tingling. Your skin may swell, bruise, or bleed. 

The place where your fracture occurs may look odd, bent, or out of place. Sometimes a broken bone may come through the skin. You may not be able to move or put weight on your limb or joint, or you may do so with difficulty.

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Diagnosis

Your doctor can diagnose a fracture with a physical examination. Your doctor will ask you to describe your injury and your symptoms. In most cases, imaging tests are ordered to confirm the fracture.

An X-ray will be ordered to identify the type and location of your fracture. Some fractures, such as stress fractures, may not show up on an X-ray. In such cases, Computed Tomography (CT) scans or Magnetic Resonance Imaging (MRI) scans may be used to take a more detailed look at your bones. X-rays, CT scans, and MRI scans are painless procedures. 

A bone scan is useful for identifying bone abnormalities from Osteoporosis or cancer. A bone scan may be used to show fractures, tumors, infection, and bone deterioration. A bone scan requires that you receive a small, harmless injection of a radioactive substance several hours before your test. The substance collects in areas where the bone is breaking down or repairing itself. 

In addition to diagnosing your fracture, your doctor will classify the type of fracture that you have in order to plan treatment appropriately. Fractures are classified by a combination of general terms used to describe their features. Fractures are categorized by the characteristics of the broken bone, including the position of the fragments or broken bone and the direction of the fracture line. Common fracture characteristics and classifications are described below.

A fracture is first classified in general terms: 

Complete Fracture: The bone is completely broken into separate pieces 
Incomplete or Partial Fracture: A crack that does not completely break the bone into two pieces 
Greenstick Fracture: An Incomplete Fracture with a bowed bone, it is more common in children
Compound or Open Fracture: The bone fragments penetrate the skin
Simple or Closed Fracture: The bone fragments do not penetrate the skin 

Fractures are further described and classified by the position of the bone fragments: 


Comminuted: The bones are broken into several pieces

Nondisplaced: The bone is broken but maintains its alignment
Displaced: The bone is broken and the fragments are out of position
Segmental: More than one fracture line leads to a "floating" segment
Angulated: The fragments are out of position and at an angle to each other
Overriding: The fragments overlap each other
Impacted: One piece of bone is forced into a second piece of bone
The fracture line or crack is also described and classified. This terminology is especially used to describe fractures in the long bones of the arms and legs: 
Linear: The fracture line is parallel with the shaft (the long part) of the bone

Transverse: The fracture line is at a right (90°) angle to the shaft of the bone
Oblique: The fracture line is at a 45° angle to the shaft of the bone
Spiral: The fracture line has a “corkscrewed,” “curled,” or angled pattern

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Surgery

Surgery is recommended for fractures that do not heal properly or when the bones have broken in such a way that they are unlikely to remain aligned when set with a cast. There are several options for surgery. The type of surgery that you have will depend on the location and type of your fracture. You can have general anesthesia for surgery or your doctor can numb the area with a nerve block. 

Surgical options include procedures called an Open Reduction and Internal Fixation or an Open Reduction and External Fixation. Open Reduction and Internal Fixation refers to techniques that use surgical hardware to stabilize a fracture beneath the skin. Your surgeon will make an incision and place your bones in the proper position for healing. Your surgeon will secure the bones together with surgical hardware, such as rods, screws, or metal plates. 

Open Reduction and External Fixation refers to techniques that use surgical hardware to stabilize a fracture from the outside of the skin. Your surgeon will make an incision and place your bones in the proper position for healing. Your surgeon will secure the bones with surgical pins that are placed through the outside of the skin. The surgical pins are attached to a metal frame on the outside of the skin.

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Recovery

Your pain will probably cease before your fracture has completely healed. Your doctor will limit your activity while your bone is healing. Physical or occupational therapy usually follows surgery or casting. Your therapists will work with you to regain movement, strength, and flexibility that may have decreased while your bone or joint was immobile.
Recovery time from a fracture is different for everyone. It depends on the type of fracture you had and the type of treatment you received. Your doctor will let you know what to expect. Generally, fractures need about 6 weeks to heal. Some fractures can take several months to heal. Most people have good outcomes with treatment and are able to return to their regular activities.

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Prevention

There are several things that you can do to help prevent fractures. Prevent vehicle crashes. Drive carefully. Wear a seatbelt. Make sure your vehicle is in good working order.

Prevent falls. A general physical examination can identify medical conditions that are associated with balance disorders or dizziness. Ask your doctor about a Bone Mineral Density Test to screen for Osteoporosis.

A vision exam can detect vision changes that are associated with falls. Some vision changes can be corrected with glasses. Additionally, people who wear bifocals or trifocal lenses should learn the correct way of walking with their glasses on. 

It can be helpful to have an occupational therapist, a physical therapist, or a family member help you examine your home and remove obstacles that may cause you to trip. Such obstacles may include throw rugs, electrical cords, and even small pets. It may be helpful to install railings on your steps or in your shower. Wear low-heeled, sturdy shoes. They may help you maintain proper foot positioning. A cane or walker may aid your balance while you stand or walk. 

If you play sports, make sure that you wear the appropriate safety equipment. Wear the safety helmets, pads, and body gear designed for your sport or activity.

Keep your bones healthy. Do not smoke. Smoking can inhibit the healing process of bones. Make sure your diet contains healthy amounts of calcium and Vitamin D. Talk to your doctor about nutrition supplements that may be appropriate for you.

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Introduction

Ganglion Cysts are a common condition.  They are not harmful or cancerous, although they may cause some people discomfort.  Ganglion Cysts usually appear as bumps on the back of the hand and at either side of the wrist.  They are also called “Bible Cysts” because in the past, treatment included hitting them with a Bible or a large book.  Today, of course that practice is no longer accepted.  Instead, individuals with Ganglion Cysts have several professional treatment options from which to choose. 

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Anatomy

Our wrist complex contains many joints.  The joints are composed of several bones in the hand and two bones in the forearm.  The wrist joints function to position our hands and fingers for movement. 
 
The bones in our hands are covered with smooth cartilage connected with ligaments.  Ligaments are firm tissues that provide support and enable us to position our hands for finger movements.  The ligaments are lined with a Synovial Membrane.  The Synovial Membrane secretes a thick liquid called Synovial Fluid.  The Synovial Fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions.  
 
Ganglion Cysts arise from the fluid filled areas on the ligaments or between the bones.  The cyst is a round sac-like structure filled with Synovial Fluid.  The fluid is harmless and not cancerous.  The fluid can become thick over time, making the cyst feel firm and spongy.  It is common for cysts to grow larger, but they will not spread to other parts of your body. 

Ganglion Cysts occur most frequently on the back of the hand and wrist.  These cysts, called “Dorsal Wrist Ganglions,” are the most common type of cyst.  Ganglion Cysts occasionally develop on the palm side of the wrist near the thumb and on the fingertips, just below the cuticle.  Ganglion Cysts can appear on the lower extremities as well.  They may form on the outside of the knee or ankle and on the top of the foot.

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Causes

Overall, Ganglion Cysts occur more often in women.  The cause of Ganglion Cysts is unknown.  One theory suggests that trauma or stress at the wrist joints may cause degeneration and the formation of cysts.  This may occur in individuals who participate in activities that are strenuous to the hand, such as gymnastics or meat cutting.  According to this theory, prior wrist injuries that are re-injured may be susceptible to Ganglion Cyst development. 
 
The second, most likely theory is that the Ganglion Cysts form because of structural flaws in the joint tissues.  The cyst may develop when Synovial Fluid collects between the joints.  As the fluid builds up, it may create a bulge where the tissues weaken.

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Symptoms

Ganglion Cysts can be so small that they are not noticeable underneath the skin.  They can also become large, over one inch in diameter.  It is very common for the cysts to increase in size.  They may also come and go or disappear forever.  The unattractive appearance of these cysts is what often leads patients to seek treatment for them.
 
Some cysts are painless, but the majority causes some degree of discomfort.  The pain is usually continuous and may become worse with activity.  You may experience a tingling sensation, considerable pain, or numbness if the cyst is pressing on a nerve.

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Diagnosis

You should have your physician evaluate a suspected Ganglion Cyst but it is not a medical emergency.  Your doctor can diagnose a Ganglion Cyst by performing an examination and talking to you about your symptoms.  Your doctor will feel your cysts and ask you about their degree of tenderness.
 
Sometimes doctors use needle aspiration to confirm the diagnosis of a Ganglion Cyst.  This simple procedure involves numbing the area and then using a syringe and needle to draw fluid from the cyst.  The fluid is examined to confirm the diagnosis and rule out any other condition. 
 
In some cases, physicians use imaging tests, such as ultrasound or Magnetic Resonance Imaging (MRI) scans, to determine more information about the cyst.  An ultrasound uses sound waves to create an image when a device is gently placed on your skin.  A MRI scan provides a very detailed view of the cyst and surrounding structures.  The MRI scan requires that you remain very still while the pictures are taken.  Both tests are painless.  The tests are helpful to determine if a cyst is fluid-filled or solid.  The images can also identify if an artery or blood vessel is causing the bump.

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Treatment

Some Ganglion Cysts require no treatment and disappear on their own.  Your doctor may recommend that you wear a wrist splint.  This can help relieve pain caused by activity and promote healing.  
 
Physicians may also use needle aspiration to treat Ganglion Cysts.  Your doctor will numb your wrist area for the procedure and remove the fluid from the cyst using a needle and syringe.  The site is injected with an anti-inflammatory steroid medication to reduce swelling.  Your wrist will be splinted following the procedure to promote healing.  Not long after the procedure, your doctor will prescribe exercises to mobilize the joints.  Needle Aspiration is a fairly successful treatment, although some individuals may need to have it repeated a few times.

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Surgery

Outpatient surgery is recommended if the Ganglion Cyst is painful, causes numbness or tingling, and interferes with functional movement.  In some cases patients want the cysts removed because of their unattractive appearance.  
 
Your surgeon will numb the area before removing the cyst.  Following the surgery, you will wear a splint on your wrist for a few days.  Your doctor may recommend occupational or physical therapy to mobilize and strengthen the joints.

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Recovery

Recovery from surgery differs from individual to individual, depending on the size of the cyst and the extent of the surgery.  Recovery typically takes from about two to six weeks.  In a few cases the cysts may return.  However, the majority of people experience successful results with surgery.

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Introduction

Golfer's Elbow (medial epicondylitis) is a type of cumulative trauma injury.  Golfer's Elbow results when the tendons that attach to the inner elbow degenerate.  Tendons do not stretch easily and are vulnerable to degeneration during repetitive motions, such as those used during a golf swing or work activities.  The pain of Golfer's Elbow occurs where the tendons attach to the elbow bone (medial epicondyle) and can radiate down the forearm.  The majority of people with Golfer's Elbow find symptom relief with non-surgical methods.  If surgery is necessary, there are open and arthroscopic methods to fix the problem.

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Anatomy

Golfer's Elbow involves the common flexor tendon that connects flexor forearm muscles to the inner (medial) side of the elbow bone (epicondyle).  The forearm muscles that flex the wrist move it downward towards the palm side of the hand.

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Causes

Repetitive motions and cumulative stress cause the tendons at the inner side of the elbow to deteriorate.  Such motions may occur while playing golf, but also during periods of muscle overuse.

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Symptoms

A main symptom of Golfer's Elbow is pain and tenderness at the inner side of the elbow that increases during wrist flexion or grasping motions.  The pain may radiate down the forearm.

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Diagnosis

A physician performs an examination and reviews the individual's medical and activity history to make a diagnosis of Golfer's Elbow.  The physician evaluates the forearm and elbow structures with simple tests.  X-Rays and, more rarely, MRI imaging, are used to confirm the diagnosis and rule out other causes of elbow pain.

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Treatment

Most cases of Golfer's Elbow respond to non-surgical treatments.  Treatment typically includes rest or activity restriction or alteration.  Specific stretching and exercises under the guidance of a therapist are often prescribed.  The therapist may use ultrasound or other modalities to promote healing.  A splint, brace, or elbow wrapping may be recommended.  Physicians may instruct the application of ice to the affected areas or recommend medication to relieve pain.  Cortisone shots are often used, but have little evidence that they are useful.

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Surgery

The majority of people with Golfer's Elbow do not require surgery.  Surgery is considered if significant pain continues after nonsurgical treatments have failed over a long time.  Surgery for Golfer's Elbow is usually an outpatient procedure.  The goal of surgery is to remove the damaged tendon and reattach the healthy tendon to the bone.  There are several approaches to the surgery including open surgery, percutaneous, and arthroscopic surgery. 

Arthroscopic surgery uses a small camera, called an arthroscope, to guide the surgery.  Only small incisions are used and the joint is not opened.  Arthroscopic surgery for Golfer's Elbow is associated with a positive outcome and potential shortened recovery time.

Elbow motion begins almost immediately following surgery, and is gradually increased per the surgeons instructions.  Full recovery from elbow surgery may take several months.

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Recovery

Recovery from Golfer's Elbow can take several months.  It is important to manage the condition with rest, rehabilitation, and lifestyle or sports modifications, such as changing the technique of a golf swing.

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Introduction

Gout is a disorder that can cause sudden joint pain.  It occurs most commonly in the big toe, although it may affect other joints.  The buildup of uric acid, a substance found naturally in the body and in certain foods, causes gout.  Episodes of gout tend to come and go.  Symptoms are treated with medications to ease pain and decrease inflammation.  Measures can be taken to help prevent gout in some cases.

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Anatomy

Uric acid is a natural substance that is found in the body.  The body uses uric acid to help break down purines, a substance found in the body and in certain foods, such as organ meats, mushrooms, and anchovies.  The kidneys eliminate uric acid in urine.  A build-up of uric acid can occur if the kidneys do not remove enough of it or if the body over produces it.  An excess of uric acid can lead to the formation of urate crystals.  The urate crystals in joints cause pain and inflammation.

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Causes

Gout is a type of arthritis that is caused by an excess of uric acid in the body.  The surplus of uric acid causes needle-shaped urate crystals to form in the joints or surrounding tissues. The urate crystals cause pain and inflammation.

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Symptoms

Gout usually begins with sudden symptoms, frequently during the night.  Gout most commonly develops in the big toe, but it can also occur in almost any joint.  Gout causes significant pain and tenderness.  The joint may appear red and swollen.

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Diagnosis

You should contact a doctor, such as a podiatrist, if you suspect that you have gout in your foot.  Diagnosis and treatment are necessary to prevent joint damage. A doctor can diagnose gout by examining your joint and conducting some tests. 

A joint fluid test is used to determine if urate crystals are in your joint fluid.  Your doctor will use a needle to draw fluid from your joint for testing.  Blood tests are used to test for the amount of uric acid in your blood.  Your doctor will interpret the results of these tests to confirm a diagnosis of gout.

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Treatment

Gout is treated with medications to relieve pain and inflammation, such as non-steroidal anti-inflammatory drugs, colchicine, and steroids.  Your doctor may prescribe medications to decrease uric acid production in your body or to help your body remove uric acid.  It may be helpful to limit foods that contain purines, such as red meat, and avoid drinking alcohol.  It may be helpful to drink plenty of water to help the kidneys eliminate uric acid.

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Prevention

You may help prevent gout by avoiding alcohol. 

Avoid eating foods that are high in purines and limit the amount of protein from meat that you eat to about 5 or 6 ounces per day.

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Introduction

Your big toes help you maintain balance. They receive a huge amount of stress each time you walk, stand, squat, or climb stairs. People with degenerative arthritis may develop a condition called hallux rigidus, meaning a “stiff big toe.” Hallux rigidus occurs when the joint at the base of the big toe wears down and makes movement difficult. Hallux rigidus is a progressive condition, and over time, the toe may become very stiff. Early treatment is important and may help prevent the need for future surgery.

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Anatomy

Your big toe (hallux) contains two bones (phalanges).  The ends of the bones meet to form two joints, one at its base, and one in the middle of the toe.  The bone ends are covered with protective cartilage.  The cartilage allows the bones to glide smoothly during motion.  The joint at the base of the toe where hallux rigidus occurs is called the metatarsophalagneal (MTP) joint.

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Causes

The exact cause of hallux rigidus is unknown.  Degenerative arthritis causes the protective cartilage in the MTP joint to wear away, causing bone on bone rubbing and stiffness.  Abnormal bone growths (bone spurs) can restrict motion as well.

Hallux rigidus most frequently occurs in people between the ages of 30 and 60.  It appears to develop after a trauma, injury, or significant stress.  Researchers do not know why some people develop hallux rigidus and others do not.

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Symptoms

Hallux rigidus causes a stiff and swollen big toe.  The pain tends to become worse during activities.  A bump or callus may develop on the top of your foot. 

Hallux rigidus is a condition that gets worse over time.  Eventually, it may be very difficult to move your big toe.  It can affect your ability to walk, stand, and participate in your regular activities.  Your toe may feel painful even when you are resting.

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Diagnosis

You should contact your doctor if you suspect that you have hallux rigidus.  Early treatment and diagnosis are associated with the best outcomes.

Your doctor can diagnose hallux rigidus by reviewing your medical history and conducting an examination.  X-rays will be taken to identify arthritis, bone spurs, and other structural abnormalities.

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Treatment

Treating hallux rigidus in the early stages can help prevent surgery in the future.  There are a variety of non-surgical treatments for hallux rigidus.  It can help to stop wearing high-heeled shoes and wear stiff soled shoes with a large toe box.  Custom orthotics can help relieve pressure and improve foot function.  Over-the-counter anti-inflammatory medications, such as ibuprofen, can help reduce pain and swelling.  For more severe symptoms, your doctor may inject the toe joint with steroid medication.

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Surgery

Surgery is recommended when non-surgical treatments fail to relieve symptoms or improve function.  There are several types of surgery for hallux rigidus.  The procedure that you receive depends on the severity and extent of your condition. 

Cheilectomy is a surgical procedure used to remove excess bone and bone spurs to allow the toe to bend.  Cheilectomy is most appropriate for mild to moderate cases of hallux rigidus.  The surgery is performed through an incision on the top of the foot.  You will need to wear a rigid sole shoe for a few weeks following surgery.  The procedure is quite successful for relieving pain for most people.

Arthrodesis (fusion) is another type of surgical procedure that is used to secure the toe joint in a permanent fixed position.  Arthrodesis is reserved for severe cases of hallux rigidus.  The procedure involves removing the damaged cartilage, aligning the bones, and securing them with surgical hardware.  Your foot will be placed in a cast for about six weeks, and you will need to walk with crutches during this period.  Over time, the bones grow together (fuse) and pain is relieved.

The toe joint may be removed and replaced with artificial implants, in a procedure called arthroplasty.  Arthroplasty is used to restore motion and relieve pain.  It can be a good option for older adults.

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Recovery

Recovery from hallux rigidus surgery depends on the severity of your condition and the treatment that you receive.  Recovery is individualized, and your doctor will let you know what to expect.

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Prevention

You should contact your doctor if you develop symptoms of hallux rigidus.  Cases that are diagnosed and treated early are associated with the best outcomes.

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Introduction

Hammertoe most commonly affects the second toe on the foot. It causes the middle joint to bend. Hammertoe is most frequently caused by structural problems in the toe or from wearing poor fitting shoes. It is important to diagnose and treat hammertoe early because the condition tends to become worse over time. If left untreated, hammertoe can require surgery.

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Anatomy

Your toes are part of your forefoot. They help you balance, walk, and move.  Your big toe (hallux) contains two bones (phalanges).  Your second through fifth toes contain three bones.  On these toes, hammertoe results when the middle joint is bent (contracted).

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Causes

Hammertoe commonly develops because of structural changes that take place over time in the muscles and tendons that bend the toes.  People with certain medical conditions, such as diabetes, are at risk for developing hammertoe.  It can be an inherited condition for some people.  Other causes include trauma and wearing shoes that are too tight, narrow, or have high heels.  The toe next to the big toe (second toe) is most frequently affected by hammertoe.

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Symptoms

The symptoms of hammertoe are progressive, meaning that they get worse over time.  Hammertoe causes the middle joint on the second, third, fourth, or fifth toes to bend.  The affected toe may be painful or irritated, especially when you wear shoes.  Areas of thickened skin (corns) may develop between, on top of, or at the end of your toes.  Thickened skin (calluses) may also appear on the bottom of your toe or the ball of your foot.  It may be difficult to find a pair of shoes that is comfortable to wear.

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Diagnosis

Your doctor can diagnose hammertoe by reviewing your medical history and examining your foot.  In most cases, X-rays are taken.

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Treatment

There are many non-surgical treatments to help relieve symptoms of hammertoe. The first step for many people is wearing the right size and type of shoe.  Low-heeled shoes with a boxy or roomy toe area are helpful.  Cushioned insoles, customized orthopedic inserts, and pads can provided relief as well.  Splints or straps may be used to help correct toe position.  Your doctor may show you toe stretches and exercises to perform.  Your doctor can safely remove corns and calluses.  You should not try to remove them at home.

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Surgery

Surgery is used when other types of treatment fail to relieve symptoms or for advanced cases of hammertoe.  There are several types of surgeries to treat hammertoe.  A small piece of bone may be removed from the joint (arthroplasty).  The toe joint may be fused to straighten it (arthrodesis). Surgical hardware, such as a pin, may be used to hold the bones in place while they heal.  Other types of surgery involve removing skin (wedging) or correcting muscles and tendons to balance the joint.

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Recovery

Recovery from non-surgical and surgical treatment for hammertoe is individualized.  Recovery can depend on several factors, including the cause and extent of your condition and the type of treatment you received.  Your doctor will let you know what to expect.

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Prevention

It is important to visit a foot specialist if you develop hammertoe.  Early treatment can help prevent future deformities.  Hammertoe that is not treated can become worse over time, requiring surgery.

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Introduction

Hamstring muscle injuries create sudden pain at the back of the thigh.  Hamstring injuries occur most frequently among athletes and dancers. The hamstring muscles can strain or tear.  Most hamstring tears do not require surgery.  Physical rehabilitation following hamstring strain or surgery usually enables a full recovery.

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Anatomy

The hamstring muscles are located at the back of the thighbone (femur).  The hamstrings attach at the pelvis bone (ischial tuberosity) and the top of the leg bones (tibia and fibula).  The three muscles that compose the hamstring are the semitendinosus, semimembranosus, and biceps femoris.  The hamstring muscles work together to bend the knee and raise the thigh to the back (extend the hip).

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Causes

A pulled hamstring most frequently occurs among dancers and athletes during sports that require sprinting, such as basketball, soccer, football, and track.  A pulled hamstring or a hamstring tear may occur when the hamstring muscles are stretched too far or receive a sudden load.

Am I at Risk

Risk factors for hamstring injuries include:
• Tight muscles
• Imbalanced muscle groups, for example if the muscle group at the front of the thigh (quadriceps) are stronger than the hamstring muscles
• Tired muscles
• Deconditioned muscles
• Adolescents during growth periods
• Older athletes
• Participation in football, soccer, basketball, running, sprinting, dance

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Symptoms

A hamstring strain causes a sudden pain in the back of the thigh.  You may fall or will be unable to put weight on your leg.  Over the next few hours, your leg will swell.  You may also experience:
• Bruising on the thigh and below the knee in the days following an injury
• Weak hamstring muscles for several weeks

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Diagnosis

A doctor diagnoses hamstring injuries by examining the affected limb. You should tell your doctor about the circumstances that lead to your hamstring injury.  Imaging tests, such as X-Rays or MRI scans may be used to determine the extent of injury and identify a hamstring tendon avulsion.

Most hamstring injuries occur in the thickest part of a muscle or where the muscle joins a tendon.  Tendons connect muscles to bones. 

A hamstring injury can be a:
• Pull or strain
• Partial tear
• Complete tear, tears from the pelvis bone are more common than tears from the leg
• Avulsion, a piece of bone pulls away when the tendon detaches from a bone

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Treatment

Doctors treat hamstring tendon injuries on an individualized basis.  The type of treatment that you receive depends on the location and degree of your injury.  Most hamstring strains are treated with non-surgical methods. 

You should rest and elevate your leg. Your doctor will recommend an icing schedule and compression bandage for your thigh.  You may temporarily use crutches or a knee splint.  Your doctor may refer you to a physical therapist for exercises to regain motion and strength.  Your doctor will let you know when you can return to sports safely.

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Surgery

Surgery is used for complete tears in the middle of a hamstring or hamstring muscles that have detached from the bone.  Orthopedic surgeons use sutures to connect the muscles in mid hamstring tears.  Hamstring muscles are reattached to bones with sutures, anchors or staples.

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Recovery

Surgery is followed by a period of rest, during which time you may wear a brace and use crutches.  Physical therapy rehabilitation exercises are important for regaining flexibility, range of motion, and function.  The rehabilitation period may last from three to six months depending on the type and location of injury.  Most people recover fully from hamstring injuries.

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Prevention

The main symptom of severe hip arthritis is dull and aching pain. You may feel pain in your hip, groin, thigh, buttock, and sometimes in the knee. Your pain may occur while you are moving or resting. It may even keep you awake at night. Your hip may feel stiff and swollen. You may have difficulty moving or lifting your leg. Your hip pain may eventually limit your everyday activities, including walking, stair climbing, and bending. Medications and physical therapy may provide little relief from the pain of severe hip arthritis.

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Introduction

Hand dislocations occur when a force causes the bones in the fingers or wrist to move out of position.  Sports, falls, job-related injuries, and motor vehicle crashes are the most common causes of hand dislocations.  Symptoms can include deformity, extreme pain, loss of motion, and loss of sensation.  The bones may spontaneously return to position, or they may need realignment by a doctor with or without surgery.

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Anatomy

Your hand consists of five digits including four fingers and a thumb.  Phalanges are the bones in your fingers.  You have three phalanges in each finger and two in your thumb.  Five metacarpal bones make up your hand above the finger.  Several small bones make up your wrist.

Two interphalangeal (IP) joints separate the phalanges on your fingers. Your thumb has one IP joint.  The IP joints allow you to bend and straighten your fingers.  Your knuckles are the metacarpophalangeal (MCP) joints.  The MCP joints allow your fingers and thumbs to move up and down and from side to side.  The carpometacarpal (CMC) joints are located between your hand and wrist.

Your hand bones are connected together by strong ligaments.  Your muscles are attached to your bones by tendons.  The tendons and muscles power your hand joints and enable them to move.  Your hands also contain blood vessels, nerves, connective tissues, and fat.

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Causes

Hand dislocations cause the bones in the hand to move out of their normal position.  The bones may spontaneously return to position or they may need realignment by a doctor.  A hand dislocation may also injure the ligaments, tendons, blood vessels, nerves, and connective tissues. 

Hand dislocations are most commonly caused by injuries during sports, such as football, basketball, and baseball.  IP joint dislocations occur most frequently during sports.  Falls on an outstretched hand are most likely to cause MCP and CMC joint dislocations.  Job-related injuries and motor vehicle crashes can also cause hand dislocations.

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Symptoms

A hand dislocation causes pain at the time of injury.  Your hand will be extremely painful when you attempt to move it.  You may not be able to or may have difficulty moving your hand.  Your hand may bruise, swell, or feel numb.  Displaced bones may cause your hand to look odd or crooked.

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Diagnosis

Your doctor can identify a hand dislocation by reviewing your medical history and examining your hand.  You should tell your doctor about your symptoms and how your injury occurred.  X-rays can show the dislocation and possible associated fractures.

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Treatment

Some joint dislocations may correct themselves spontaneously.  Other joints may need to be moved back in place by a doctor in a procedure called a closed reduction.  The procedure is termed “closed” because the skin on the hand does not need to be surgically opened to realign the joints.

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Surgery

Open reduction surgery is used for joints that cannot be realigned with closed reduction methods.  In many cases, ligaments or tendons are trapped in the joint and obstruct closed reduction attempts.  Open reduction surgery is used to remove the trapped tissues and realign the joints.

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Recovery

Splinting and hand therapy usually follows closed or open reduction of hand dislocations.  The recovery process is different for everyone and depends on many factors including the location of your dislocation and the type of treatment you received.  Recovery can take many weeks.  Your doctor will let you know what to expect.

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Introduction

Your heels bear tons of pressure each day when you stand and walk.  It’s no wonder that heel pain is a common complaint.  Heel pain occurs for a variety of reasons, from wearing the wrong type of shoes to abnormal growths or tendon problems.  Fortunately, most cases of heel pain can be treated without surgery.  Talk to you doctor if you have heel pain.  Early diagnosis and treatment can help prevent bigger problems.

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Anatomy

Your heel bone is called the calcaneus.  It helps to bear and distribute your body weight across your foot when you stand or walk.  Many soft tissues that help move and shape the foot are attached to the calcaneus.

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Causes

Heel pain occurs for various reasons.  Common causes of pain beneath the heel include bruising from stepping on something hard, inflamed connective tissue from overuse (plantar fasciitis), and irritated nerves under the heel.  Rubbing from poorly fitted shoes, inflamed connective tissue (bursitis), or an inflamed tendon (Achilles tendon) most frequently cause pain behind the heel.

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Symptoms

Symptoms of heel pain vary depending on the cause.  It may develop gradually or occur suddenly.  It may be accompanied by redness, thickened skin, or swelling.

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Diagnosis

Your doctor will review your medical history and examine your heel to determine the cause of your pain.  X-rays will be taken to check for bone abnormalities.

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Treatment

Treatment for heel pain depends on several factors, including the cause and extent of the underlying condition.  In many cases, rest, physical therapy, pain relievers, injections, proper shoes, and sole inserts can relieve symptoms.  When such treatments fail, surgery may be recommended.

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Surgery

Surgery may be used to relieve pressure from a nerve, remove an abnormal bone growth, or treat an inflamed tendon.  Most surgeries for heel pain are performed as outpatient procedures.  Following surgery, you will most likely participate in physical therapy to regain strength and motion.

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Recovery

Recovery is an individualized process and depends on your condition and the treatment you received.  Your doctor may recommend that you wear customized shoe inserts or orthopedic shoes.  Your doctor will let you know what to expect.

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Introduction

Heel spurs are abnormal bony growths that develop at the back of or under the heel.  Inflammation around a spur, more so than the spur itself, can cause significant pain.  Fortunately, symptoms can be eased with non-surgical treatments for the vast majority of people.

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Anatomy

Your heel bone is called the calcaneus.  It helps to bear and distribute your body weight across your foot when you stand or walk.  Soft tissues that help move and shape the foot are attached to the calcaneus.  One such tissue, the plantar fascia, forms the arch in the foot.

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Causes

Heel spurs develop in some people that have a condition called plantar fasciitis, inflammation of the plantar fascia.  Heel spurs form when the plantar fascia separates from the calcaneus.  An abnormal bone growth, a hook-like spur, forms from calcium deposits that grow at the site of inflammation. 

Heel spurs are more common in middle-aged adults and people that have had plantar fasciitis for a long time.  People with flat feet or high arches are vulnerable to heel spurs.  Women who wear high-heeled shoes are more susceptible, as well.

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Symptoms

Heel spurs may or may not cause symptoms.  Symptoms are usually related to the plantar fasciitis.  You may experience significant pain.  Your heel pain may be worse in the morning when you first wake up or during certain activities.

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Diagnosis

Your doctor will review your medical history and examine your foot.  X-rays are used to identify the location and size of the heel spur.

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Treatment

The majority of heel spurs are treated with non-surgical interventions.  These can relieve pain, but may take from about 3 months to up to a year for symptoms to resolve.  Rest, icing, and over-the-counter anti-inflammatory or prescription medications can help ease symptoms.  Cortisone injections may also be used.

You may be instructed to perform stretching exercises to help relax the tissues in the heel.  Your doctor may recommend custom orthotics or shoe inserts to position and cushion your heel. Night splints can help position the heel and arch of the foot while you sleep.

Some doctors may recommend extracorporeal shock wave therapy (ESWT).  This treatment uses energy pulses to start the repair process in the heel tissues.  ESWT is recommend when other non-surgical treatments have failed.

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Surgery

Surgery is used a very small percentage of the time.  It is usually considered after trying non-surgical treatments for at least a year.  Plantar fascia release surgery is use to relax the plantar fascia.  This surgery is commonly paired with tarsal tunnel release surgery.  Surgery is successful for the majority of people.

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Recovery

Recovery from non-surgical heel spur treatment can take considerable time, usually from three months to a year.  However, most doctors agree that non-surgical treatments should be tried for at least one year before considering surgery.

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Prevention

You can help prevent heel spur symptoms from returning by wearing the proper shoes.  Customized orthotics and insoles can help relieve pressure.  It is important to perform your exercises to help keep your foot stretched and relaxed.

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Introduction

A herniated disc, also called a “ruptured” disc, is a common source of neck or lower back pain.  Discs are cushion-like pads that are located between the series of small bones that make up the spine.  A herniated disc occurs when the outer disc layer tears and it’s gel-like interior comes out.  The contents can irritate nerves.  A herniated disc can cause pressure on the nerves or spinal cord.  Fortunately, for the vast majority of people, pain related to a herniated disc can be relieved without surgery

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Anatomy

The spine is made up of a series of small bones called vertebrae.  The different areas of the spine are defined by their curvature and function.  The cervical spine is located in the neck, the thoracic spine is in the chest, and the lumbar spine is in the lower back.  Herniated discs occur most frequently in the cervical and lumbar spine.

The opening in the center of each vertebra forms the spinal canal.  Your spinal cord is inside of the protective spinal canal.  Nerves extending from the spinal cord exit the spine and travel throughout your body, sending messages between your body and brain.

Intervertebral discs are located between the vertebrae.  A disc and two facet joints connect one vertebra to the next, allow movement, and provide stability.  The discs are made of strong connective tissue.  Their tough outer layer is called the annulus fibrosis and their gel-like center is called the nucleus pulposus.  A healthy disc contains about 80% water, which allows it to act as a shock-absorbing cushion between the bones.

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Causes

With age, the discs lose water content.  The discs become narrower, less flexible, and less effective as cushions between the vertebrae.  As a disc deteriorates, the annulus fibrosis (outer layer) can tear or rupture.  A herniated disc results when the nucleus pulposus (inner contents) come out of the disc. 

In addition to the natural aging process, herniated discs can result after sudden pressure.  Impacts from trauma, violence, and motor-vehicle crashes can cause a herniated disc. Abrupt forces during sports, such as football or surfing, can cause a herniated disc, as well.

If the nucleus pulposus extends into the spinal canal, it can cause pressure on the spinal cord and spinal nerves.  When the inner contents come in contact with the spinal nerves, a chemical reaction occurs.  The spinal nerves become irritated and inflamed, resulting in pain.

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Symptoms

The type of symptoms that you experience depends on the location of the herniated disc in your spine.  Herniated discs most frequently occur in the cervical (neck) and lumbar (lower back) spine.  Pain is a major symptom of a herniated disc, regardless of its location.

Neck pain is a common symptom of a herniated cervical disc.  You may feel shooting pain in your arms.  You may experience pain or burning pain in your shoulders, neck, and arms.  Your arm(s) may feel weak, numb, or have a tingling sensation.  You may experience a headache at the back part of your head. 

Low back pain is a symptom of a herniated disc in the lumbar spine.  Sciatica is the most frequent symptom of a herniated disc in the lower back.  Sciatica is shooting pain that travels through the buttocks and down the back of one leg.  One of your legs or buttocks may feel weak, numb, or have a tingling sensation. 

In rare cases, the loss of bowel and bladder control along with significant arm and leg weakness indicates a serious problem.  In this rare case, you should seek emergency medical attention.  Call 911 or go to the nearest emergency department of a hospital.

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Diagnosis

Your doctor can diagnose a degenerative disc by performing a physical examination and some tests.  You will be asked about your symptoms and medical history.  Muscle strength, joint motion, and stability will be tested.  Because the nerves from the spine travel to the body, your doctor will perform a neurological examination of your arms and legs to see how the nerves are functioning.

Your doctor will order X-rays to see the condition of the vertebrae in your spine.  Dye may be used to enhance the X-ray procedures in a procedure called a myelogram.  A myelogram is used to help determine if there is pressure on your spinal cord or nerves from a herniated disc.

Additional imaging tests, such as a computed tomography (CT) scan, discogram, or magnetic resonance imaging (MRI) scans may be ordered.  A discogram is another type of imaging test that provides a view of the internal structure of a disc to help identify if it is a source of pain.  A discogram is usually immediately followed by a CT scan to show more detail about the extent of the rupture or tear pattern, as well as the size and shape of the disc.  The MRI scan is the most sensitive imaging tool.  The MRI provides the most detailed images of the discs, ligaments, spinal cord, and nerve roots. 

In some cases, a nerve conduction velocity (NCV) test is used to measure how well the spinal nerves work.  During the NCV test, a nerve is stimulated in one place and the amount of time it takes for the message or impulse to travel to a second place is measured.  Before the NCV test begins, sticky patches with electrodes will be placed on your skin that covers the spinal nerve that is being evaluated.  The NCV may feel uncomfortable, but only during the time that the test is conducted. 

An electromyography (EMG) test is often performed at the same time as the NCV test.  An EMG measures the nerve impulses within a muscle.  Healthy muscles need nerve impulses to perform movements.  Your doctor will place fine needles into the select muscles that a spinal nerve controls.  The EMG allows your doctor to determine the amount of nerve impulses that are conducted when your muscle contracts.  An EMG may be uncomfortable, and your muscles may remain a bit sore following the test.

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Treatment

The vast majority of people with herniated discs are successfully treated with non-surgical pain management treatments aimed at relieving pain and restoring function.  Over-the-counter medication or prescription medication may be used to ease your pain.  If your symptoms do not improve significantly with these medications, your doctor may inject your spine with corticosteroid medication to relieve pain at the source of the problem.

A short period of rest may be recommended.  Your doctor may initially restrict your activity level and body positioning.  You should avoid lifting, bending forwards, and quick abrupt movements.  You may wear a back or neck brace for support.  It can help to take brief walks and avoid sitting for prolonged periods.

Your activity level will gradually be increased by your doctor.  You may be referred to physical therapy.  Occupational or physical therapists can provide treatments to help reduce your pain, muscle spasms, and swelling.  The therapists will teach you exercises to help strengthen your neck muscles or back and abdominal muscles.

Non-surgical pain management treatments for herniated disc are designed to relieve pain and restore function, but they cannot correct structural abnormalities in a disc or the spine.  For some people, surgery may be recommended if non-surgical treatments do not provide relief, if there is pressure on a nerve, and if there is considerable loss of function.  An anterior cervical diskectomy and fusion (ACDF) is a common surgery for a herniated disc in the cervical spine.  A microdiskectomy or laminectomy are surgeries used to treat a herniated disc in the lumbar spine.

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Am I at Risk

Herniated discs are more common among people that are middle-aged.  Older adults are at the greatest risk for herniated discs because of the decreased disc water content. 

Risk factors for herniated disc include:
• Being overweight 
• Smoking 
• Using poor body posture when lifting 
• Performing repetitive strenuous activities

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Introduction

A herniated or “ruptured” discis a common source of neck pain and arm pain.  Discs are the shock-absorbing pads that are between vertebrae, the series of small bones that make up your spine.  Your cervical spine is located in your neck.  At the cervical spine, the discs and joints allow your neck to move and provide stability for your head.  The discs also act as a cushion to protect the cervical vertebrae.  
 
An opening in the center of each vertebra forms the spinal canal.  Your spinal cord and spinal nerves run through the protected canal and send messages between your body and brain.  A herniated disc occurs when its outer layer ruptures and the contents come out of the disc.  If the contents extend into the spinal canal, it can put pressure on the spinal nerves.  A herniated disc can cause shoulder, neck, or arm tingling, pain, numbness or weakness.  It can also cause headaches.
 
Most cases of herniated discs resolve with non-surgical treatments.  However, when conservative treatments fail, surgery, called an Anterior Cervical Discectomy and Fusion, is recommended to relieve pain and restore function.

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Anatomy

The spine is divided into regions defined by their curvature and function.  The cervical spine is located in your neck.  The cervical spine supports your head and connects it to your trunk.  The cervical spine supports less weight than any other portion of the spine.  It also has the greatest amount of mobility and flexibility.  Your neck can bend forward and backward or tilt from side to side.  Your neck can also turn or rotate to the right and left, a motion used when checking for traffic before crossing a street.
 
Seven small vertebrae make up the cervical area of your spine.  Vertebrae are the series of small bones that align to form the spine.  The back part of the vertebra arches to form the lamina.  The lamina creates a roof-like cover over the back opening in each vertebra.  The opening in the center of each vertebra forms the spinal canal.  
 
Traveling through the protective cervical spinal canal is your spinal cord, spinal nerves that travel to your arms and hands, and arteries that supply blood.  The top section of the cervical spinal canal is very spacious.  It allows more room for the spinal cord than any other part of the vertebral column.  The extra space helps to prevent pressure on the spinal cord when you move your neck.
 
Intervertebral discs are located between the vertebrae in your cervical spine.  The discs are made up of strong connective tissue.  Their tough outer layer is called the annulus fibrosus.  Their gel-like center is called the nucleus pulposus.  The discs and two small spinal facet joints connect one vertebra to the next.  The discs and joints allow movement and provide stability.  The discs also act as a shock-absorbing cushion to protect the cervical vertebrae. 

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Causes

As we age, our discs lose water content.  Our discs can become shorter, less flexible, and less effective as cushions between the vertebrae.  When a disc deteriorates, the outer layer can tear.  A herniated disc occurs when the outer layer ruptures and the inner contents, the nucleus pulposus, come out of the disc. 
 
If the inner contents of a herniated disc extend into the spinal canal, it can cause pressure on the spinal nerves.  When the inner contents come in contact with the spinal nerves, a chemical reaction occurs.  The spinal nerves become irritated and swell, resulting in pain.  A herniated disc can also cause pressure on the spinal cord.
 
Herniated discs are more common among people that are middle aged.  Older adults are at the greatest risk for herniated discs because of their decreased disc water content.  Other risk factors include being overweight and smoking.  Using poor body posture when lifting or performing repetitive strenuous activities can also cause discs to rupture.  

Additionally, a disc can rupture after sudden pressure, even if it is slight.  This can occur from trauma during violence, motor-vehicle crashes, or from a sports-related injury, such as football or surfing.

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Symptoms

Neck pain is a common symptom of a herniated cervical disc.  You may feel shooting pain in your arms.  You may experience pain or burning pain in your shoulders, neck, and arms.  Your arm may feel weak, numb, or have a tingling sensation.  You may also get a headache.  In rare cases, the loss of bowel and bladder control accompanied by significant arm and leg weakness indicates a serious problem.  In this rare case, you should seek immediate medical attention.

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Diagnosis

Your doctor can diagnose a herniated disc by performing a physical examination and viewing medical images. Your doctor will ask you about your symptoms and medical history. You will be asked to perform simple movements to help your doctor assess your muscle strength, joint motion, and stability.  Since some of the nerves from the cervical spine travel to the arms, your doctor will perform a neurological physical exam to see how the nerves are functioning.

Your doctor will order X-rays to see the condition of the vertebrae in your cervical spine.  Sometimes doctors inject dye into the spinal column to enhance the X-ray images in a procedure called a myelogram.  A myelogram can indicate if there is pressure on your spinal cord or nerves from herniated discs, bone spurs, or tumors.

Your doctor may also order Computed Tomography (CT) scans or Magnetic Resonance Imaging (MRI) scans to get a better view of your spinal structures.  CT scans provide a view in layers, like the slices that make up a loaf of bread.  The CT scan shows the shape and size of your spinal canal and the structures in and around it.  The MRI scan is very sensitive.  It provides the most detailed images of the discs, ligaments, spinal cord, nerve roots, or tumors.  X-rays, myelograms, CT scans, and MRI scans are painless procedures.

In some cases, doctors use nerve conduction studies to measure how well the cervical spinal nerves work and to help specify the site of compression.  Doctors commonly use a test called a Nerve Conduction Velocity (NCV) test.  During the study, a nerve is stimulated in one place and the amount of time it takes for the message or impulse to travel to a second place is measured.  Your doctor will place sticky patches with electrodes on your skin that covers a spinal nerve.  The NCV may feel uncomfortable, but only during the time that the test is conducted.

An Electromyography (EMG) test is often done at the same time as the NCV test.  An EMG measures the impulses in the muscles to identify nerve problems.  Healthy muscles need impulses to perform movements.  Your doctor will place fine needles through your skin and into the muscles that the spinal nerve controls.  Your doctor will be able to determine the amount of impulses conducted when you contract your muscles.  The EMG may be uncomfortable, and your muscles may remain a bit sore following the test.

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Treatment

Many people with herniated discs can be treated with non-surgical methods.  Over-the-counter medication or prescription medication may be used to reduce pain.  These may include steroids or nonsteroidal anti-inflammatories.  
 
Your doctor may recommend that you rest for a few days.  You may wear a soft neck collar to provide support.  Occupational or physical therapists can provide treatments to reduce your pain and muscle spasms.  The therapists will also show you exercises to strengthen your neck muscles.  
 
Following surgery, your doctor will initially restrict your activity level and body positioning.  You should avoid lifting, housework, and yard-work until your doctor gives you the okay to do so.  You will wear a neck brace for support.  You will gradually increase your activity level.  Once your neck has healed, physical therapists will teach you flexibility and strengthening exercises.  You will also learn body mechanics, proper postures for your spine to use when you stand, sit, and lift objects.

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Surgery

Surgery is recommended when non-surgical methods have provided minimal or no improvement of your symptoms.  Surgery may also be required in cases where a herniated disc is pressing directly on a nerve or the spinal cord and causing loss of function.  An anterior cervical discectomy and fusion is the type of surgery most frequently used for a herniated cervical disc.
 
An anterior cervical discectomy and fusion involves removing all or part of a herniated disc or discs.  The surgeon also fuses or secures two or more vertebrae together to stop movement and relieve pain caused by the disc herniation.  The surgeon performs the surgery through a small incision on the anterior or front part of the neck.  
 
Your surgeon will make an incision approximately two inches long on the front of your neck, carefully avoiding your throat and airway.  Your muscles and arteries will be moved aside with care to allow access to the vertebrae.  Your surgeon will remove all or part of the herniated disc.  
 
Next, the surgeon places a bone graft or interbody fusion cage in the empty disc space.  A bone graft consists of bone taken from your own body, usually from the pelvis, or an allograft taken from a donor.  The bone grafts are placed between the vertebrae.  An interbody fusion cage is a small container that is filled with bone shavings and placed between the vertebrae.  The bone grafts are surgically secured to the spinal column with surgical hardware, such as screws and plates.  The surgical hardware secures the vertebrae together and allows the bone grafts to heal, fusing together the vertebrae.
 
At the completion of your anterior cervical discectomy and fusion, your surgeon will close your incision with stitches.  You will receive pain medication immediately following your surgery. You will wear a neck brace or collar while your fusion heals.

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Recovery

You should expect to stay overnight in the hospital.  You may need a little help from another person during the first few days or weeks at home.  If you do not have family members or a friend nearby, talk to your doctor about possible alternative arrangements.
 
Your doctor will initially restrict your activity level and body positioning.  You should avoid lifting, housework, and yard-work until your doctor gives you the okay to do so.  You will wear a neck brace for support.  You will gradually increase your activity level.  Once your neck has healed, physical therapists will teach you strengthening exercises.  You will also learn body mechanics, proper postures for your spine to use when you stand, sit, sleep, and lift objects.
 
The recovery process is different for everyone.  It depends on the type of surgery that you had and the extent of your condition.  Your surgeon will let you know what to expect.  Generally, the recovery time for an anterior cervical discectomy and fusion is several weeks.  Your arm pain should go away fairly quickly; however, it may take weeks to months for your arm weakness and numbness to resolve.

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Prevention

It is important that you adhere to your restrictions and exercise program when you return home.  You should use proper body mechanics during all activities.  Do not smoke.  Smoking increases the risk of surgical complications and hinders the bone from fusing.

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Introduction

It takes a lot of force to fracture the bones in the hindfoot.  A fracture is a broken bone. Injuries most frequently result from car crashes or falls from a significant height.  Fractures may occur in the heel or the bone located on top of the heel.  Hindfoot fractures take a long time to heal, with or without surgery.

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Anatomy

The bones in your hindfoot include the calcaneus, known as the heel, and the talus, which is located on top of it.  The talus forms the ankle joint with the two leg bones that are positioned on its upper side.  The hindfoot bears and distributes your body weight across your foot when you stand or walk. 

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Causes

High impact forces cause hindfoot fractures.  They may result from a vehicle crash, a fall from a height, and as is becoming more common, snowboarding.

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Symptoms

Hindfoot fractures cause pain, swelling, stiffness, and bruising.  You will not be able to put weight on your foot to stand or walk.

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Diagnosis

You should contact your doctor right away if you suspect that you have fractured your hindfoot.  Prompt diagnosis and treatment can help prevent further problems.  Your doctor will review your medical history, conduct an examination, and order imaging tests.  X-rays and computed tomography (CT) scans are used to show the location of your fracture and if the broken bones have moved out of place or not.

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Treatment

In select cases, hindfoot fractures with bones that have not moved out of place may be treated without surgery.  You may wear a cast or a splint to position your foot while the bone heals.  The bone will take about six to eight weeks to heal, during which time you will not be able to put weight on your foot.  You will need to use a walker or crutches to stand or walk.

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Surgery

Surgery is necessary for most hindfoot fractures if the bones have moved out of place.  During surgery, the bones are realigned in the proper position and secured with surgical hardware.  Sometimes a bone graft is needed to fill in the gaps from crushed bone.

Following surgery, a protective cast or splint is worn while your bones heal.  You will not be able to put any weight on your foot for about 6-10 weeks.  You may need to use a cane or wear a special boot when you first begin walking.

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Recovery

Physical therapy usually follows any treatment for hindfoot fracture.  You will learn exercises to increase motion and strength in the ankle joint.  Your physical therapist will help you learn to walk with assistance, gradually increasing the amount of weight that you can put on your foot as you gain independence.  Overall, hindfoot fractures can take a long time to heal, some up to a year.  Your doctor will let you know what to expect.

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Prevention

You can help prevent future complications by receiving prompt professional care for a hindfoot fracture.  If left untreated, arthritis, deformity, and problems using the foot are likely to develop in the future.

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Introduction

Humerus fractures are common.  The humerus is the long bone in your upper arm.  A fracture is a broken bone.  The humerus is most frequently fractured as the result of a fall or motor vehicle crash.  Depending on the location and severity of the fracture, some bones may heal without surgery.  Fractures that are very unstable are realigned and held in place with surgical hardware.  Physical rehabilitation usually follows either form of treatment and is an important part of recovery to regain use of the shoulder and upper arm.

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Anatomy

The humerus is the long bone that connects your shoulder to your elbow.  The head of the humerus (proximal humerus) is attached to the shoulder by the rotator cuff muscles.  The long part of the bone is called the shaft.  The distal humerus is the end of the bone that connects with the forearm to form the elbow.

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Causes

Trauma is the main cause of humerus fractures.  Most injuries result from a direct impact to the body, such as during a fall or motor vehicle crash.  Older adults may experience humerus fractures from relatively minor falls.

There are different types of humerus fractures.  They are named for the area of the bone that is broken.  Proximal humerus fractures occur near the shoulder.  Mid-shaft fractures are located in the middle of the bone.  Distal humerus fractures are located near the elbow joint and are more common in children than in adults.

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Symptoms

Humerus fractures cause severe pain and swelling.  It may be very difficult for you to move your upper arm.  If the nerves are affected, you may experience unusual sensations in the hand and weakness in your hand and wrist.

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Diagnosis

Your doctor can diagnose a fractured humerus by examining your arm and taking X-rays.  In rare cases, more sophisticated imagery, such as a computed tomography scan is used to provide a more detailed view.

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Treatment

If the fractured bones are still in their proper position, a sling can be used to support and keep the arm from moving while it heals.  Most mid-shaft humerus fractures can heal with  immobilization and usually do not require surgery.  Casting is not commonly used. 

Your doctor will determine when you can begin physical therapy.  Your therapists will help you move your shoulder joint at first with passive range of motion exercises.  These exercises help improve circulation and reduce stiffness.  You will proceed to more advanced exercises to increase strength and motion.

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Surgery

If the fractured bones have moved out of position, surgery is recommended.  Surgery called an Open Reduction and Internal Fixation (ORIF) is used to realign the bones and secure them in position with surgical hardware, such as plates, pins, screws, and wires.  Surgery is most frequently used for proximal and distal humerus fractures.

For severe proximal humerus fractures, a shoulder replacement surgery is used to remove the damaged bone and insert an artificial implant.  Severe proximal humerus fractures may also require reattachment of the shoulder muscles (rotator cuff muscles).  Rehabilitation therapy, as described above, begins as soon as possible.

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Recovery

The recovery process is different for everyone, depending on the severity of the injury and the treatment you received.  Most fractures heal in about 4 to 6 weeks, but severe injuries may take longer to heal.  Your doctor will let you know what to expect.

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Introduction

Kienbock’s disease is a progressive condition that affects the lunate bone in the wrist.  It occurs when there is a disruption of the blood supply to the lunate bone.  Without a proper blood supply, the lunate bone decays and dies.  Kienbock’s disease can eventually affect the structure and function of the wrist.  Kienbock’s disease is treated with immobilization, anti-inflammatory and pain medications, and surgery.

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Anatomy

The lunate bone is one of the small bones in the wrist.  The lunate bone is part of the proximal carpal row.  It is part of the radiocarpal and midcarpal joints.  The midcarpal joint allows your hand and wrist to move upwards and towards the thumb side.  The radiocarpal joint allows you to lower your hand and wrist and move it towards the little finger side of your hand.

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Causes

The exact cause of Kienbock’s disease is unknown.  It occurs when there is a disruption of the blood supply to the lunate bone.  Your bones need blood to live.  Without a blood supply, the lunate bone decays and dies.  Kienbock’s disease can eventually affect the structure and function of the wrist.

Blood flow to the lunate bone may be disrupted by trauma, such as a fall.  Overuse of the dominant hand is suspected to contribute to Kienbock’s disease.  People that are born with just one artery to supply the lunate, instead of two, are at risk for developing Kienbock’s disease.

Kienbock’s disease affects more men than women.  It most frequently develops in individuals between the ages of 20 and 40 years old.  It appears to develop more commonly in the dominant hand.

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Symptoms

The initial symptom of Kienbock’s disease is pain.  Kienbock’s disease can cause your wrist to feel painful, stiff, and tender.  Your wrist may appear swollen.  You may not be able to move your wrist as far as you used to be able to.  Your hand and grip strength may become weaker, making it difficult for you to hold objects.  

Kienbock’s disease is a progressive condition, meaning that it can get worse over time.  As the lunate bone degenerates, symptoms may become worse.  Kienbock’s disease can lead to arthritis and loss of wrist function.

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Diagnosis

Your doctor can diagnose Kienbock’s disease by examining your wrist and conducting tests.  You should tell your doctor about your symptoms and any recent trauma to your hand.  Your doctor will take an X-ray of your wrist.  X-rays may be normal during the initial stages of Kienbock’s disease.  A MRI scan or CT scan may be used to show more detailed images.

Your doctor will determine what stage your Kienbock’s disease is in.  The condition specifically progresses through four stages.  In the first stage, X-ray may be normal and symptoms are similar to a sprained wrist.  In stage two, the lunate bone hardens.  This can be seen on x-ray.  Pain, swelling, and tenderness increase.  In the third stage, the lunate bone collapses and breaks into pieces.  The other bones in the wrist may shift position as the lunate bone deteriorates.  People with stage three Kienbock’s disease experience an increase in symptoms plus grip weakness and limited movement of their wrist.  In the final stage of Kienbock’s disease, the surfaces of nearby bones are affected, and arthritis develops in the wrist.

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Treatment

The treatment that you receive will depend on the stage of Kienbock’s disease that you have.  For beginning stages, splints or casts may relieve pressure on the lunate and restore the blood flow.  Medications may help ease pain and reduce swelling.  More advanced stages of Kienbock’s disease may be treated with surgery.

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Surgery

There are several surgical options for Kienbock’s disease.  The most appropriate choice for you depends on the stage of your condition, your activity level, and your expected outcome.  Your surgeon will discuss options with you.  In some cases, the blood supply can be surgically restored to the lunate bone.  This type of procedure is called revascularization surgery.  In another surgical procedure, lengthening or shortening the lower arm bones can reduce the pressure on the lunate.  Bones are made longer with bone grafts.  Bones are made shorter by removing a section of the bone.  These are referred to as joint leveling procedures. 

A severely damaged lunate bone can be removed.  The bones on each side of the lunate may also be removed in a procedure called a proximal row carpectomy.  This surgery can help to relieve pain while allowing partial wrist movement.

Another type of surgery involves fusing, a procedure that connects several small bones in the wrist.  Fusion can relieve pressure on the lunate.  Fusion does not improve wrist movement.  If arthritis is present, fusion can help relieve pain and maintain the wrist movement that you have.

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Recovery

Kienbock’s disease is a progressive condition that gets worse over time.  There is no cure for Kienbock’s disease.  However, surgical and nonsurgical treatments can relieve symptoms, maintain motion, and sustain wrist function.

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Introduction

The knee is the largest joint in our body. It is one of the most easily injured joints. Our knees are exposed and vulnerable to sport or work injuries. Knee problems can also occur from disease, aging, or “wear and tear.” Arthroscopic Knee Surgery, also called Arthroscopy, is the most accurate procedure to both diagnose and treat knee conditions. 

Arthroscopy allows surgeons to see, diagnose, and treat problems inside the knee joint. Before arthroscopic surgery existed, surgeons made large incisions that affected the surrounding joint structures and tissues. They had to open the knee joint to see it and perform surgery. An arthroscopy requires small incisions and is guided by a small viewing instrument or "scope.” Arthroscopy is less invasive than traditional surgical methods. It has a decreased risk of infection and a shorter recovery period.

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Anatomy

The knee is one of the more complex joints in our body. Our knee is composed of three bones. The Femur, or thighbone, is positioned on top of the Tibia, or larger leg bone. The Patella, or kneecap, glides in a groove on the end of the femur. Large muscle groups in the thigh give the knee strength and stability.

Four ligaments connect our knee bones together. The ligaments are strong tissues that provide stability and allow motion. The Medial Collateral Ligament is located on the inner side of our knee. The Lateral Collateral Ligament is at the outer side of our knee. These two ligaments help the joint to resist side to side stress and maintain positioning.

The Anterior Cruciate Ligament and the Posterior Cruciate Ligament cross inside of the knee joint. These two ligaments help to keep the joint aligned. They resist excessive forward and backward forces and prohibit displacement of the bones. They also produce and control rotation of the tibia. We rotate our tibia when we turn our leg outward to push off the ground with our foot. We use this motion to push off from the side when skate, run, or move our body to get into a car. 

Two cartilage disks, called Menisci, are located on the end of the tibia. The cartilage forms a smooth surface and allows our bones to glide easily during motion. The menisci also act as a shock absorber when we walk or run. 

A smooth tissue capsule covers the bones in our knee joint. A thin synovial membrane lines the capsule. The synovium secretes a thick liquid called synovial fluid. The synovial fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions.

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Causes

Knee problems can occur from injury, disease, aging, or “wear and tear.” Any of the knee ligaments may be torn by an injury, especially during sports. The Medial Collateral Ligament most frequently tears during football, basketball, and volleyball. The Anterior and Posterior Cruciate Ligaments are frequently injured during football. 

The menisci are a common location of injury and disease. Meniscal injury usually occurs when the femur rotates suddenly and forcefully, while the tibia remains in a fixed position. The torque can cause the menisci to tear or fragment and become loose. This type of injury can occur in football when a player is tackled or clipped from the side. 

Overuse and “wear and tear” can cause the ligaments and synovium to become inflamed. They may swell and feel painful. Inflammation of the synovial membrane can occur with rheumatoid or gouty arthritis, as can bone deterioration. The knee bones can be fractured or broken during an injury. The patella may come out of its normal alignment and become unstable. The patella is commonly fractured from falls directly onto the knee.

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Symptoms

Swelling and continuous pain are hallmark symptoms of knee injuries. Your knee may feel like it has a catch in it when you move it. It may suddenly give way as you stand or walk, causing you to fall.

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Treatment

Most knee conditions can be treated with non-surgical methods. This includes medication, knee bracing, and physical rehabilitation. Arthroscopy is recommended when such treatments have provided minimal or no improvement of your symptoms. Arthroscopy is commonly used to reconstruct ligaments and remove or repair torn meniscal cartilage, synovium, or bone fragments. Your doctor will discuss your examination results and help you decide on your course of treatment.

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Surgery

Almost all arthroscopic knee surgeries are performed as outpatient procedures. You will be asked to complete a physical examination prior to your surgery. You may be sedated for the surgery or receive a local or regional anesthetic. Local anesthesia will numb your knee area, and regional anesthesia will numb you below the waist. General anesthesia may also be used. 

Before the operation, your surgeon will elevate your leg and apply a tourniquet, an inflatable band. This will reduce the blood flow to your knee during the procedure. 

Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert the arthroscope and may reposition it to see your joint from different angles. 

If you are having surgical treatment, your surgeon may make additional small incisions and use other slender surgical instruments. 

When your procedure is completed, your surgeon may inject your joint with medication to reduce pain and inflammation. Because the incisions are so small, they will require just a few stitches or Steri-Strips. Your surgeon will cover them with a bandage.

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Recovery

After surgery, you will be instructed to elevate your leg and apply ice to your joint to help reduce pain and swelling. Your surgeon may restrict your activity and may recommend that you wear a knee brace for a short period of time following your procedure. You will need to use crutches, a walker, or a cane to help you walk at first. 

Your surgeon will instruct you regarding how much weight to put on your leg, depending on your procedure. Physical therapy is recommended to help you move and strengthen your knee. 

Your recovery time will depend on the extent of your condition and the amount of surgery that you had. Your surgeon will let you know what to expect. It usually takes a joint several weeks to several months fully recover. 

Your doctor may set temporary or permanent physical restrictions for you depending on your type of injury. Your injury itself may restrict you form performing certain activities. For instance, if part of your menisci needed to be removed, you may be restricted from performing running activities or lifting large amounts of weight. 

Some individuals with certain ligament injuries will need to wear a knee brace for walking. Return to intense physical activity should only be done under the direction of your surgeon. 

It may be helpful to avoid significant weight bearing impact and twisting movements at the knee. Restrictions are very individualized and your surgeon will discuss them with you. 
Overall, arthroscopic knee surgery requires a shorter length of time for recovery than open joint surgery. It also has a reduced risk of infection and causes minimal pain and stiffness because only small incisions are used and less surrounding tissue is affected or exposed. Most individuals achieve good results.

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Prevention

Once you have injured your knee, it is important to avoid another knee injury. Talk to your surgeon about your activity precautions. It can be helpful to exercise to keep the muscles around your knee joint strong.

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Introduction

Knee tendon bursitis can develop at the inner (medial) knee. Knee tendon bursitis results from trauma, overuse, and degenerative joint disease.  The painful inflammatory condition develops most frequently in athletes, middle-aged women with obesity, and older adults with arthritis.  Knee tendon bursitis rarely requires surgery.  Conservative measures, including rest, physical therapy, and medications provide symptom relief for most people.

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Anatomy

Tendons are fibrous tissues that attach muscles to bone.   The pes anserinus tendons secure the muscles that flex and rotate the knee. Pes anserinus means "goosefoot," which describes the appearance of the conjoined tendons that attach to the inner side of the leg bone (tibia bone).  Beneath the pes anserinus tendons is a bursa (pes anserine).  The bursa is a small cushion-like sac that creates fluid to allow the pes anserinus tendons to glide over the bone.

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Causes

Knee tendon bursitis is an inflammation of the bursa.  Athletic overuse, trauma, chronic arthritis, degenerative joint disease, and obesity, especially in middle-aged women, are frequent causes of knee tendon bursitis.

The incidence of knee tendon bursitis is highest among:
• Middle-aged women with obesity
• Young athletes who participate in sports that require abrupt side-to-side motions or cutting.  Such sports include basketball, tennis, and soccer.
• Older adults with arthritis
• People with flat feet
• People with bowlegged knee deformity

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Symptoms

Knee tendon bursitis causes swelling, tenderness, and pain with certain movements, such as when climbing stairs or getting up from a chair. 

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Diagnosis

A doctor diagnoses knee tendon bursitis by examining the knee and reviewing your medical history.  Your doctor may order medical imaging tests, such as ultrasound or MRI scans to confirm the diagnosis.  

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Treatment

Knee tendon bursitis is treated first with rest and non-steroidal anti-inflammatory medications (NSAIDS) to relieve pain.  Physical therapy modalities, such as icing, therapeutic ultrasound, and exercise can help relieve pain and restore functional movement.  Muscle wasting is a concern from disuse of the knee, especially in older adults and people with obesity. People with obesity should discuss healthy weight loss and weight management plans with their physician.  If symptoms persist, injections of local anesthetics, corticosteroids, or both medications help to provide some immediate relief.

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Surgery

Surgery is rarely necessary for knee tendon bursitis.  Surgery may be used to treat people, such as athletes, with disability.  Surgery involves removing the bursa and any bone growths.

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Introduction

A Lisfranc fracture occurs in the bones of the midfoot.  The fracture results from dropping something heavy on the foot or twisting the foot during sports or in a car accident.  If you suspect you have a Lisfranc fracture, you should see your doctor right away for prompt treatment.  Some Lisfranc fractures can heal with casting and physical therapy.  Bones that have moved out of place typically require surgery. 

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Anatomy

The Lisfranc joint is located where the small bones of the midfoot (tarsals) and long bones of the forefoot (metatarsals) meet.  The Lisfranc joint adjusts and regulates the position of the forefoot based on the position of the hindfoot.

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Causes

Lisfranc fractures can occur if a heavy object is dropped on the foot or if the foot twists forcefully.  This can result from motor vehicle crashes and contact sports.  A bone in the joint may break or be forced from its position (dislocate).

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Symptoms

Lisfranc fractures can cause pain when you stand.  You may not be able to stand on your foot or walk.  Your foot may swell and bruise and appear deformed.  A Lisfranc fracture is commonly mistaken for a sprained foot.

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Diagnosis

It is important to contact your doctor to receive a correct diagnosis and treatment.  Untreated Lisfranc fractures can lead to foot deformities and foot problems in the future.  You should tell your doctor about your symptoms and the events leading up to your injury.

Your doctor will review your medical history and conduct an examination.  Imaging studies such as X-rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI) scans are used to confirm the fracture location and identify dislocated bones.

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Treatment

The treatment that you receive depends on the extent and severity of your injury.  A combination of non-surgical treatments is used if the bones did not dislocate.  A cast is placed on the foot to keep it in the proper position while the fracture heals.  During this time, you will need to keep weight off your foot and walk with crutches.  When the cast is removed, physical therapists will teach you exercises to help you gain motion and strength.

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Surgery

Surgery is used to place dislocated bones in the correct position and stabilize fractures while they heal.  Surgical hardware, such as pins, screws, or wires, are placed during surgery to hold the bones in alignment.  You will wear a cast and use crutches for about six to eight weeks.  After the surgical hardware is removed, you will wear a rigid walking brace or shoe.  You may participate in physical therapy to help you move your foot and walk.

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Recovery

Recovery is individualized and depends on the extent of your condition and the treatment that you received.  It is common for arthritis to develop after a Lisfranc fracture, requiring additional treatment in the future.

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Prevention

It is important to follow your doctor’s instructions for keeping weight off your foot or refraining from certain activities while your fracture heals.  You should perform your physical therapy exercises at home as instructed. 

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Anatomy

The lumbar spine is located in your lower back.  It curve below your waist. The lumbar spine connects your upper body-- your head, trunk, and arms, to your lower body--your pelvis and legs. Strong ligaments and muscles connect to your spinal column. They provide back stability and movement. The lumbar spine primarily allows you to bend forward or flex and extend or straighten at the waist. You use lumbar flexion when you bend forward to touch your toes. You use lumbar extension when you straighten your back to stand erect after bending forward.

Five large vertebrae make up the lumbar area of your spine. The back part of the vertebra arches to form the lamina. The lamina creates a roof-like cover over the back opening in each vertebra. The opening in the center of each vertebra forms the spinal canal. Your spinal cord and spinal nerves travel through the protective spinal canal. The spinal nerves extend from your lower back, through your buttock, legs, and down to your feet.

Your spinal cord and spinal nerves at the lumbar spine level send signals for sensation and movement between your brain and lower body muscles. Your spinal cord tapers near the first lumbar vertebra and forms a group of nerves called the cauda equina. The cauda equina is involved with regulating bowel and bladder functions.

Six intervertebral discs are located between the vertebrae in your lumbar spine. The discs are made up of strong connective tissue. Their tough outer layer is called the annulus fibrosus. Their gel-like center is called the nucleus pulposus. The discs and two small spinal facet joints connect one vertebra to the next. The discs and joints allow movement and provide stability. The discs also act as a shock-absorbing cushion to protect the lumbar vertebrae.

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Causes

Low back pain is caused by abnormalities in the soft tissues, nerves, discs, or vertebrae of the lumbar spine. The soft tissues--muscles, tendons, and ligaments, can strain from over exertion, poor posture, lifting activities, physical stress, and injury. Soft tissue injuries can cause painful muscle spasms or tightening of the lower back muscles.

Compressed, pinched, or irritated spinal nerves can cause symptoms that extend from the low back, through the buttocks and legs, and down to the feet. This commonly occurs from structural changes in the spine. Bone spurs, abnormal bone overgrowths caused by Osteoarthritis, can grow in to the spinal canal or nerve root openings on the vertebrae. Bone spurs and some degenerative diseases can also contribute to a condition in which the spinal canal is narrowed, called Spinal Stenosis. Some degenerative diseases cause the spinal structures to thicken and extend into the spinal canal over time. The narrowed canal causes pressure on the spinal cord and nerves.

If the sciatic nerve is compressed or inflamed, a painful condition called Sciatica can result. The sciatic nerve extends from your lower back down to your foot. Trauma, spinal conditions, or medical conditions that irritate the sciatic nerve cause Sciatica. If the spinal nerves in the lower end of the lumbar spine are compressed, a condition called Cauda Equina Syndrome may result. Cauda Equina Syndrome can cause the loss of bladder and bowel control, along with leg pain, sensory deficits, and weakness.

Changes in the intervertebral discs can also cause low back pain. As we age, our discs lose water content. They become shorter and less flexible, a condition called Degenerative Disc Disease. Once the discs are injured, they do not have the blood supply to repair themselves and they deteriorate. Osteoarthritis and Rheumatoid Arthritis also cause the discs and vertebrae to deteriorate. Normally, the discs act as a cushion between the vertebrae. Without the disc cushioning effect, pain can occur. Without the protective disc, the spine can become structurally unstable and unable to tolerate stress. Degenerative Disc disease can also lead to a herniated disc.

A herniated disc occurs when the outer disc layer, the annulus, ruptures. When the inner content, the nucleus pulposus, comes out of the disc, it can cause pressure on the nerve tissue. When the inner contents of the disc come in contact with the spinal nerves, a chemical reaction occurs that causes irritation and swelling.

Some conditions can directly affect the integrity of the vertebrae. Osteoporosis is a medical condition that causes more bone calcium to be absorbed than is replaced. It contributes to vertebral fractures and deterioration. Spondylolisthesis is a condition that results when a weakened vertebrae slips out of alignment. Another condition, Spondylosis, results when Osteoarthritis or a fracture causes disc degeneration and the overgrowth of bone. Spondylosis causes stiff and painful joints.

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Symptoms

The type of symptoms that you experience depends on the cause of your low back pain. Your pain may spread to your buttocks, legs, and feet. Your back may feel stiff, and you may not be able to completely move it. Your hips, legs, and feet may feel weak. You may also have numbness or tingling in your legs, feet, or toes. If you experience a loss of bowel or bladder control, you should seek medical attention immediately. A list of common causes of spinal related lower back pain and a description of symptoms is listed below.

Degenerative Disc Disease may or may not cause symptoms. If you have symptoms, you may feel various types of pain in your back. You may experience sudden pain after an injury or your pain may start gradually and increase over time. Your pain may be so intense that it interferes with your daily activities. You may feel burning pain, pressure, numbness, or tingling. Sitting may make your symptoms increase, whereas lying down may help to relieve pain. Pain is a common symptom of a herniated lumbar disc. You may experience a shooting pain that extends from your buttocks through the back of one leg. Your leg or buttock may feel weak, numb, or have a tingling sensation.

Spinal Stenosis may or may not produce symptoms. If you have symptoms, you may feel pain or numbness in your lower back. Your legs may cramp. They may feel weak, numb, or painful. Your symptoms may come and go. They may vary in intensity. Prolonged standing or walking may cause your symptoms to increase. If you bend forward or sit, your symptoms may be relieved. These positions increase the room in the spinal canal and take pressure off of the spinal cord.

Pressure on the spinal cord or spinal nerves can cause symptoms that radiate to your feet. Symptoms of Sciatica include shooting pain, tingling, weakness, and numbness that may travel from the lower back, through the back of one leg, and into your foot. You may feel burning pain, tingling, weakness, or numbness in your calf, foot, or toes. The weakness may be so bad that you cannot move your foot, bend or extend your knee, or walk. You may have difficulty moving from a seated position to standing up because of shooting pain. Additionally, your pain may become worse when you sneeze, laugh, cough, bend backwards, or have a bowel movement.

Cauda Equina Syndrome can cause the loss of bladder and bowel control. Other symptoms of Cauda Equina Syndrome include low back pain, leg pain, leg weakness, lower body sensory deficits, and reduced or absent leg reflexes. If you experience these types of symptoms, you should seek medical attention immediately.

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Diagnosis

Your doctor can determine the cause of your low back pain. The cause must be identified in order to treat your symptoms appropriately. Your doctor will perform a physical examination. Your doctor will ask you about your symptoms and medical history. You will be asked to perform simple back and leg movements to help your doctor assess your muscle strength, joint motion, and joint stability. Your doctor will test the reflexes and sensation in your legs. Your doctor may order lab studies to rule out diseases or conditions that can cause low back pain but are unrelated to the spine.

Your doctor may order imaging studies to identify the location and source of your low back pain. Your doctor will order X-rays to see the condition of the vertebrae in your lumbar spine and to identify fractures, misalignment, narrowed discs, or thickened facet joints. A Flexion and Extension X-ray can determine if there is instability between your vertebrae. For a Flexion and Extension X-ray, you will lean as far forward and then as far backward as you can. Sometimes doctors inject dye into the spinal column to enhance the X-ray images in a procedure called a myelogram. A myelogram can indicate if there are pinched nerves, herniated discs, bone spurs, or tumors.

A bone scan may be used to show fractures, tumors, infections, or arthritis. A bone scan requires that you receive a small harmless injection of a radioactive substance several hours before your test. The substance collects in your bones in areas where the vertebrae are breaking down or repairing bone.

Your doctor may also order Computed Tomography (CT) scans, a Discogram, or Magnetic Resonance Imaging (MRI) scans to get a better view of your spinal structures. CT scans provide a view in layers, like the slices that make up a loaf of bread. The CT scan shows the shape and size of your spinal canal and the structures in and around it. A CT scan is useful for determining which disc is damaged. Your doctor may inject dye into the disc area to enhance the CT images in a procedure called a Discogram. A Discogram provides a view of the internal structure of a disc and can help to identify if it is a source of pain. The MRI scan is very sensitive. It provides the most detailed images of the discs, ligaments, spinal cord, nerve roots, or tumors. X-rays, myelograms, bone scans, CT scans, and MRI scans are painless procedures and simply require that you remain motionless while a camera takes the pictures.

Nerve conduction studies reveal how the lumbar spinal nerves are working. Doctors commonly use a Nerve Conduction Velocity (NCV) test. During the study, your spinal nerve is stimulated in one place and the amount of time it takes for the message or impulse to travel to a second place is measured. The place where the impulse travels slowly at is where the nerve is compressed. Your doctor will place sticky patches with electrodes on your skin that covers the spinal nerve. The NCV test may feel uncomfortable, but only during the time that the test is conducted.

An Electromyography (EMG) test is often done at the same time as the NCV test. An EMG measures the impulses in muscles to identify atrophy or decay. Healthy muscles need impulses to perform movements. Your doctor will place fine needles through your skin and into the muscles that the spinal nerve controls. Your doctor will be able to determine the amount of impulses conducted when you contract your muscles. The EMG may be uncomfortable, and your muscles may remain a bit sore following the test.

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Treatment

The treatment for low back pain depends on its cause, severity, and duration. The majority of low back symptoms are treatable with pain medications, short periods of rest, and exercise. 

You may wear a back belt at the onset of pain for support. Over-the-counter medication or prescription medication may be used to reduce your pain. If your symptoms do not improve significantly, your doctor may inject your back with pain relieving medication. 

Physical therapists can provide treatments to reduce you pain, and muscle spasms. They will show you exercises to gently stretch and strengthen your back and abdominal muscles. Your therapists will also show you proper postures or body mechanics to use during movements, such as how to position your back when lifting. The use of proper body mechanics can help to prevent further injury.

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Surgery

Non-surgical treatments for low back pain are designed to relieve pain and restore function, but they can not correct structural deformities, such as narrowing of the spinal canal. Surgery is recommended when non-surgical methods have provided minimal or no improvement of your symptoms. Surgery may be required if a herniated disc, bone spur, or narrowed spinal canal is pressing directly on a nerve or the spinal cord. Surgery may also be required to stabilize a fractured vertebra after a traumatic injury. The goals of lumbar spine surgery are to remove the pressure from the nerves or spinal cord and establish spinal stability. There are several options for surgery, depending on the cause of the low back pain. Some of the more common surgeries are described below.

A Laminectomy is the most common surgery for Spinal Stenosis. This surgery is also used for relieving the symptoms of Sciatica caused by a disc herniation. The goal of a Laminectomy is to relieve the pressure on the spinal cord and nerves by enlarging the spinal canal where it has narrowed. To do so, the surgeon removes all or part of the lamina on the affected vertebrae. If all of the lamina is removed, the procedure is called a Laminectomy. A Laminotomy involves removing only part of the lamina.

A Discectomy is a type of surgery used to remove the part of a disc or fragments of bone that are putting pressure on the spinal cord or nerves. A Discectomy may be required if a herniated disc is pressing directly on a nerve or the spinal cord and causing considerable pain. In select cases, a Discectomy can be performed arthroscopically. Arthroscopic surgery uses small specialized tools and a small incision. It can be performed under local anesthesia and has a shorter recovery time than traditional surgery. However, an Open Discectomy is the type of surgery most frequently used for a lumbar herniated disc. Commonly, this is performed through a small incision and with the use of a microscope. This is called a microdiscectony. In some cases, a Discectomy is performed in combination with a Spinal Fusion.

Spinal Fusion is the type of surgery most frequently used for Degenerative Disc Disease. Spinal Fusion involves fusing or securing the vertebrae together after removing the degenerative or herniated disc. The purpose of Spinal Fusion is to stop motion between spine segments, and relieve pain caused by this movement. 

There are a variety of techniques for Spinal Fusion surgery. The surgeon may approach the spine from the front or back. There are also many methods used for fusing the bone together. The surgeon may use a bone graft or interbody fusion cage and special surgical hardware. A bone graft consists of small strips of bone taken from your hip during surgery. The bone grafts are placed in the empty disc space between the vertebrae. An interbody fusion cage is a small container that is filled with bone shavings and placed between the vertebrae. The bone grafts are surgically secured to the spinal column with surgical hardware, such as screws and rods. The surgical hardware secures the vertebrae together and allows the bone grafts to heal, fusing together the vertebrae.

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Recovery

Recovery from surgery depends on the cause of your low back pain and the type of surgery that you received. Most surgeries require at least an overnight stay in the hospital. Your doctor will let you know what to expect. You may need the help of a second person during the first few days or weeks when you return home. If you do not have a friend or family member nearby, talk to your doctor about alternative arrangements. Your doctor will also let you know when it is okay for you to drive again.

Individuals usually participate in physical therapy following surgery. You may initially wear a back brace for support during activities. Your therapists will show you how to strengthen your back, increase your flexibility, and use proper body mechanics. It is important to use proper body mechanics or postures during back motions and activities, such as lifting. Some individuals may need to modify their activities, such as heavy lifting, to prevent future injuries. Overall, most individuals achieve good results with surgery and are able to resume their regular lifestyles.

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Prevention

It is important that you adhere to your restrictions and exercise program when you return home. It is important to keep your muscles strong and flexible. You should use proper body mechanics when lifting, sitting, and moving your body.

It can be helpful to maintain a healthy weight. Do not smoke. Smoking increases the risk of surgical complications and hinders bone fusing. Do not drive until your doctor has given you permission to do so.

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Introduction

Magnetic resonance imaging (MRI) is an imaging procedure that produces very detailed pictures of internal body structures.  It is a non-invasive method that allows doctors to check for abnormalities and diagnose medical conditions, such as blood clots, tumors, and orthopedic injuries.  The MRI machine uses a high-powered magnetic field and radio waves to send signals to a computer where images are created.  The images are enhanced and stored in the computer.  MRI scans may be used for almost any part of the body.
 
Preparation
 
MRI is usually performed at an outpatient radiology center or the radiology department of a hospital.  You will need to remove metal objects from your body, such as jewelry, watches, pens, eyeglasses, pocket knives, and removable dental ware.  Tell the staff if you have a pacemaker, cochlear implant, surgical hardware, breast tissue expander, neurostimulators, IVC filter, penile implant, older vascular stents, or silver backed medicated skin patches.  People with heart pacemakers should not have MRIs.  Let the staff know if you have claustrophobia, a fear of small confined spaces.  You may receive a sedative prior to the procedure to help you relax.  Some types of MRIs may require fasting prior to the test.  You will receive specific preparation instructions when you schedule your appointment.
 
Procedure
 
You will lie on a narrow table, and the technician will position your body.  Small devices, called coils, may be placed by your body to enhance the images.  You may also receive contrast dye that is administered through an IV line.  
 
Once you are positioned, the technician will step back into the control room.  You will be able to communicate with the technician via a microphone at all times.  The table will slide into the MRI machine.  You will be asked to remain motionless while the images are taken.  MRI is a painless procedure.  
 
The MRI machine will make a loud thumping or humming noise when in use.  You may receive earplugs or headphones to wear.  The length of the test depends on the area being studied and the specifics of the examination.  MRIs can take from as little as a few minutes to over one hour.  
 
A radiology technician may perform your test, but is not qualified to diagnose or discuss your condition or results with you.  A radiologist or your doctor will review the results with you.

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Introduction

A mallet finger injury occurs when the tip of a finger or the thumb is forcefully flexed.  The force injures the tendon that straightens the fingertip joint.  A mallet finger injury is also referred to as a baseball fingerinjury because it commonly occurs during the sport of baseball. 

A mallet finger injury causes loss of movement, pain, and swelling.  The joint at the end of the finger is noted to droop.  Most mallet finger injuries are treated with splinting.  In cases of fracture or malalignment, surgery may be necessary to treat the condition.

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Anatomy

Your fingers are made up of three bones called phalanges.  Two joints separate the phalanges.  The distal interphalangeal (DIP) joints are located near your fingertips.  The proximal interphalangeal (PIP) joints are located in the middle of your fingers. 

Extensor tendons are attached to your phalanges . The extensor mechanism covers the entire finger.  The extensor tendons allow your fingers to extend (straighten).

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Causes

A mallet finger injury occurs when the tip of a finger or the thumb is forcefully bent down (flexed).  The force tears the extensor tendon that is attached to the distal phalanx.  This can happen during sports, such as baseball.  If the force is great enough, the tendon may remain intact, but a small piece of bone can be pulled away where it attaches to the phalanx.  This is called an avulsion fracture.  A mallet finger can also occur if the extensor tendon is cut.

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Symptoms

A mallet finger injury will cause pain and swelling at your DIP joint.  You will not be able to straighten the end of your fingertip.  The end of your finger will droop down.

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Diagnosis

Your doctor can diagnose a mallet finger injury by examining your finger.  You should tell your doctor about how you sustained your injury.  X-rays will be used to identify an avulsion fracture, joint malalignment, or associated injuries. 

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Treatment

The majority of mallet finger injuries are treated with splinting.  You will wear a finger splint full time for about six weeks.  It is important not to remove the finger splint at any time, even while you shower.  If the finger splint is removed, even for the shortest amount of time, the treatment is disrupted and the process must start all over.  The full time splint schedule is followed by a part time splint wearing schedule for another three or four weeks.
 
The splint should be removed, however, in a certain way, to allow observation and care of the skin.  The finger must be kept in extension by resting it on a flat surface whenever the splint is removed.

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Surgery

Surgery may be necessary for mallet finger injuries with fractures and joint malalignment.  Surgical hardware, such as pins, wires, and screws, are used to hold the bones in place while they heal.  In rare cases, the extensor tendon may be tightened or repaired with a graft.

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Recovery

Splinting and surgical treatments are usually followed by hand therapy rehabilitation.  A hand therapist will show you exercises to stretch and strengthen your joints.  The other joints in your fingers may become stiff and benefit from hand therapy exercises as well.  It can take a mallet finger injury several months to heal fully.  Healing is an individualized process.  Your doctor will let you know what to expect.

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Prevention

If you receive a mallet finger injury, you should elevate your hand above the level of your heart and apply ice intermittently until you can get to your doctor’s office.  You should receive medical attention if you experience bleeding beneath your fingernail.  Mallet finger injuries that receive prompt treatment tend to have better outcomes. 

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Introduction

Mallet toe most commonly affects the longest toe on the foot, although any toe can be affected.  It causes the joint closest to the tip of the toe to bend downward.  Mallet toe is most frequently caused by structural problems in the toe or from wearing poor fitting shoes.  It is important to diagnose and treat mallet toe early when the joints are still flexible, because the condition tends to become worse over time.  Joints that become rigid or fixed can require surgery to place the bones in proper position.

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Anatomy

Your toes are part of your forefoot.  They help you balance, walk, and move.  Your big toe (hallux) contains two bones (phalanges).  Your second through fifth toes contain three bones.  Mallet toe results when the joint nearest the tip of the toe (DIP joint) is bent (flexed) downward or angled to the right or left side

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Causes

Overall, mallet toe occurs less frequently than other types of toe deformities.  Mallet toe commonly develops because of structural changes that take place over time in the muscles and tendons that bend the toes.  People with certain medical conditions, such as diabetes, arthritis, or stroke, are at risk for developing mallet toe.  People with high arches in their foot may be more susceptible to mallet toe.  It can be an inherited condition.  Other causes include trauma and wearing shoes that are tight or have high heels.  The longest toe on the foot is most frequently affected by mallet toe.

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Symptoms

The symptoms of mallet toe are progressive, meaning that they get worse over time.  Mallet toe causes the end joint on the toe to bend downward.  At first, the joint may be moveable, but overtime, the joint can become fixed or rigid.

The affected toe may be painful or irritated, especially when you wear shoes.  Areas of thickened skin (corns) may develop between, on top of, or at the end of your toes.  People with diabetes are especially vulnerable for developing a sore (skin ulcer) on the tip of the toe.  Thickened skin (calluses) may appear on the bottom of your toe or the ball of your foot.  It may be difficult to find a pair of shoes that is comfortable to wear.  A mallet toe can eventually interfere with walking.

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Diagnosis

Your doctor can diagnose mallet toe by reviewing your medical history and examining your foot.  X-rays will be taken.  In some cases, nerve studies may be conducted.

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Treatment

There are many non-surgical treatments to help relieve symptoms of mallet toe. The first step for many people is wearing the right size and type of shoe.  Low-heeled shoes with a boxy or roomy toe area are helpful.  Cushioned insoles, customized orthopedic inserts, and pads can provide relief as well.  Your doctor may show you toe stretches and exercises to perform. 

Your doctor can safely remove corns and calluses.  You should not try to remove them at home.

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Surgery

Surgery is indicated when other types of treatment fail to relieve symptoms or the toes have become rigid or cross over each other.  There are several types of surgery to treat mallet toe.  A tendon may be lengthened or a small piece of bone may be removed from the joint (arthroplasty).  Surgical hardware, such as a pin, may be used to hold the bones in place while they heal.  In extreme cases, a toe may need to be surgically removed (amputated). 

You may need to use crutches or a walker for a short time following surgery. Your doctor will direct you to gradually increase the amount of weight that you put on your foot.

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Recovery

Recovery from non-surgical and surgical treatment for mallet toe is individualized.  Recovery depends on several factors, including the cause and extent of your condition and the type of treatment you received.  Some surgeries can take between 6 and 12 weeks for a full recovery.  Your doctor will let you know what to expect.

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Prevention

It is important to visit a foot specialist if you develop mallet toe.  Early treatment can help prevent future deformities.  Mallet toe that is not treated can become worse over time, leading to a fixed joint and possible surgery.

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Introduction

The menisci are cartilage structures in the knee joint that act as buffers between the bones.  The menisci are vulnerable to injury, especially during twisting motions used for sports.  Some tears in certain parts of the meniscus may heal on their own, but in many cases surgery is necessary.  Arthroscopic surgery is the accepted method of treating meniscus tears.  Because the joint is not fully opened, recovery is faster and has fewer complications than with older open surgery methods.

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Anatomy

The knee joint is composed of three bones.  The thigh bone (femur) sits on top of the larger leg bone (tibia).  The kneecap (patella) glides in a groove on the end of the thigh bone.  The menisci are two C-shaped cartilage discs that are located on the end of the tibia. 

The outer edges of the menisci have a blood supply, which can allow injuries to heal.  The inner part of the menisci does not have a good blood supply, and tears in this area cannot heal on their own.  The menisci help to support your body weight and act as shock absorbers when you walk or run.  They also allow your knee bones to glide easily during motion.

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Causes

The menisci can tear during strong twisting motions of the knee, especially when the foot remains firmly planted on the ground and the knee is bent.  Pivoting, cutting, changing directions quickly, or slowing down quickly during sports, such as football, tennis, or soccer, can cause a meniscus tear.  Older adults can experience a meniscus tear as the result of weakened cartilage and knee degeneration.

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Symptoms

You may hear a popping noise when the meniscus tears.  Swelling, pain, and tightness may increase over several days.  You may not be able to straighten your knee, and it may buckle, catch, or lock in position.  It may be difficult for you to put weight on your leg or walk.

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Diagnosis

You should contact your doctor if you suspect you have torn your meniscus.  Your doctor will review your medical history, the circumstances leading to your injury, and conduct a physical exam.  Clinical exams, the McMurray’s test and Apley’s compression test, involve bending your knee while the doctor moves your foot and leg in different positions to assess the menisci.  Your doctor will evaluate excess fluid and swelling around your knee joint.  An X-ray may be used to see the condition of your bones. A magnetic resonance imaging (MRI) scan may be used to create a picture of your menisci and inner knee structures to help your doctor diagnose your injury

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Treatment

Minor tears on the outer sections of the meniscus may be able to heal on their own if there is a good blood supply.  Ice packs, rest, and medications can help relieve pain and swelling.  Physical therapy can help strengthen the muscles that move the knee joint.  Your doctor may recommend a knee brace for sports or custom shoe inserts to support the arch of the foot.

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Surgery

Surgery may be recommended for larger tears on the outer section of the meniscus or for tears in the inner areas.  Most meniscus repairs are performed as outpatient surgeries.  You can be anesthetized for surgery so you are not alert or receive a nerve block to numb your knee and leg area.  Arthroscopic surgery is  favored because it is less invasive and is associated with less pain, swelling, infection, and bleeding and has a faster recovery time than open surgery.

An arthroscope is a very small surgical instrument.  It consists of a narrow tube that contains a lens and a lighting system that allows a surgeon to see inside of the joint.  Narrow surgical instruments are inserted through small incisions.  With an arthroscope,  only  small incisions, about ¼” to ½” in length, are needed, and the joint does not need to be fully opened. 

After making the small incisions, the surgeon will fill the joint space with a sterile saline (salt-water) solution.  The fluid expands the joint and allows your surgeon to have a better view of your knee.  Next, the arthroscope is inserted.  It may be repositioned to view the joint from various angles.  Your surgeon may make additional small incisions and use other slender surgical instruments to trim torn meniscus pieces.  A surgical shaver is used to smooth the remaining meniscus.

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Recovery

After surgery, you will be instructed to elevate your leg and apply ice to your joint to help reduce pain and swelling.  You may wear a cast or knee brace for a short period of time.  You will need to use crutches, a walker, or a cane to help you stand and walk, at first.  Your surgeon may initially restrict the amount of weight that you can put on your foot but will gradually increase it as you heal.  Physical therapy will help you gain strength and movement in your knee.

The recovery time is different for everyone.  It depends on the extent of your condition and the type of surgery that you had.  Full recovery can take several weeks or months. 

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Prevention

Your doctor may set restrictions on your activities depending on the nature of your injury.  For example, if part of your meniscus is removed, you may be restricted from running activities or lifting large amounts of weight.  Return to intense physical activity should only be done with the clearance of your doctor.  You should always wear your knee brace or protective sports gear as directed by your surgeon.

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Introduction

Your forefoot acts as a springboard with each step you take, and a cushion when your foot touches the ground.  The metatarsal bones located in the forefoot bear and shift your body weight to help maintain balance.  Jumping, twisting, dancing, and running add even more force to the forefoot, making the bones vulnerable to fracture from trauma and overuse.  The majority of metatarsal fractures heal with non-surgical treatment.  Fractures that require surgery have highly successful outcomes.

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Anatomy

Your forefoot (metatarsus) contains five long metatarsal bones.  As a group, the metatarsal bones help raise and lower or twist your foot.  They play a role in distributing your body weight and maintaining balance when you walk or stand. 

Certain parts of the metatarsals have a better blood supply than others .  Fractures in areas of poor blood supply have more difficulty healing.  For example, a Jones Fracture is such a fracture near the base of the fifth metatarsal that commonly requires surgery.

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Causes

Metatarsal fractures are caused by stress from overuse, improper training, ankle twisting, or trauma.  Stress fractures are common in soccer players, ballet dancers, and military recruits.

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Symptoms

A metatarsal fracture can cause pain, swelling, discoloration, and difficulty walking.  When the metatarsal bones crack or break, they may remain in place or move out of position (displace).

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Diagnosis

Your doctor can diagnose a metatarsal fracture by reviewing your history and examining your foot.  X-rays are taken to help identify the fracture.

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Treatment

The majority of metatarsal fractures are treated without surgery.  You may need to wear a walking cast or rigid shoe.  Some people may need to wear a cast and not put weight on their foot for several weeks while the fracture heals.

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Surgery

Significant metatarsal fractures with a poor blood supply, or bones that have moved out of place may require surgery.  Surgical hardware, such as a plate and screws are used to secure the bones in place.  You may wear a short leg cast, brace, or rigid shoe for 6 to 8 weeks while the bones heal.  Your doctor will check the healing process with X-rays and allow you to put more weight on your foot as the fracture heals.

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Recovery

Recovery is individualized and depends on the location and extent of your injury, as well as the treatment that you received.  Your doctor will let you know what to expect.  Overall, metatarsal surgery has a high degree of success.

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Introduction

The hip is one of the most frequently replaced joints. Osteoarthritis, a type of arthritis, is the main reason for hip replacement surgery. Other conditions, including trauma, may also require the need for a hip replacement. 

Arthritis is a disease that causes joint pain, stiffness, immobility and swelling. It can affect the cartilage and bone in the hip joint. Cartilage is a very tough, shock absorbing material that covers the ends of many of our bones. The cartilage forms a smooth surface and allows the bones in our joints to glide easily during motion. Arthritis can cause the cartilage to wear away. Loss of this protective lining can cause painful bone on bone rubbing. 

While the symptoms of hip arthritis may be tolerated with some medications and lifestyle adjustments, there may come a time when surgical treatment is necessary. One type of hip replacement surgery is called Minimally Invasive Hip Arthroplasty. Like traditional total hip replacement surgery, it involves removing the damaged portion of the hip and replacing it with artificial implants called a prosthetics. These devices are a replacement for the natural joint and allow pain-free movement. 

Minimally Invasive Hip Arthroplasty uses smaller incisions than traditional surgery. This allows individuals to experience less pain, spend less time in the hospital, and have shorter recovery times.

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Anatomy

Our hip joint is a ball-in-socket joint. Our thigh bone is called the femur. The top of the femur is shaped like a ball. It is called the femoral head. Our pelvic bone has a cup-shaped socket that holds the femoral head in place and allows it to rotate during movement. The cup-shaped socket is called the acetabulum. The acetabulum and the femoral head form our hip joint. Bands of strong tissue ligaments connect the femoral head to the acetabulum and provide stability.

The surfaces of the bones in the hip joint are covered with articular cartilage. This is a strong smooth cover that cushions the ends of our bones and allows them to move easily. The remaining surfaces of our hip joint are covered with synovial membrane. This smooth thin tissue secretes synovial fluid that lubricates the joint and eliminates friction between the bones. 

The hip is one of our body’s largest weight-bearing joints. The primary function of the hip joint is to support the weight of our head, trunk, and arms. The hip joint provides a base of support that allows us to hold our body upright when we sit or stand. Likewise, it provides stability for our upper body while positioning the lower body for movement. The hip joint allows our legs to move to the front and back and from side to side as we walk, run, and climb stairs. It also allows our legs to rotate inward and outward. We rotate our legs when we place our feet on the ground. We angle our toes inward or outward for balance.

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Causes

Arthritis is a major cause of joint pain, stiffness, and swelling in the hip. Arthritis can occur for many reasons, including aging, “wear and tear,” injury, disease, and developmental abnormalities in the hip structure. There are over 100 different types of arthritis. Osteoarthritis, Post-Traumatic Arthritis, and Rheumatoid Arthritis are types of arthritis that frequently develop in the hip.

Osteoarthritis is the most common type of arthritis and affects millions of Americans alone. It tends to develop as people grow older. Osteoarthritis can result from overuse of the hip during sports or work. Post-Traumatic Arthritis can develop in individuals of all ages after a hip injury, such as a fracture. 

Osteoarthritis causes the articular cartilage covering the end of the bones to gradually wear away, resulting in painful bone on bone rubbing. Abnormal bone growths, cysts or spurs, can grow in the hip joint. They add to the pain and swelling, while disrupting movement. 

Rheumatoid Arthritis is one of the most serious and disabling types of arthritis. Rheumatoid Arthritis can affect people of all ages, but most frequently occurs in women and those over the age of 30. It is an autoimmune disease that causes the synovial membrane to become inflamed. This damages the articular cartilage and leads to pain and stiffness. 

Traumatic Arthritis can develop after a severe hip injury or fracture. A hip fracture can cause a condition called Avascular Necrosis. This medical condition causes a lack of blood flow to the femoral head and leads to bone and tissue death. Avascular Necrosis can cause articular cartilage damage, resulting in hip pain and stiffness.

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Diagnosis

Your doctor can diagnose arthritis by conducting a physical examination. You will be asked about your medical history, symptoms, and level of pain. You will be asked to perform simple hip and leg movements to help your doctor assess your muscle strength, joint motion, and hip alignment. Blood tests and other laboratory tests may identify what type of arthritis you have.

Your doctor will order X-rays to see the condition of your bones and to identify areas of arthritis, bone cysts, or bone spurs. Sometimes the tissues that surround the hip joint or the condition of the bones do not show up on an X-ray. In this case, your doctor may order Magnetic Resonance Imaging (MRI) scans or a bone scan. An MRI is used to obtain more detailed images of the soft tissues. A bone scan identifies the location of abnormal growths in a bone, such as arthritis. A bone scan requires that you receive a small harmless injection of a radioactive substance several hours before your test. The substance collects in your bones in areas where the bone is breaking down or repairing itself. X-rays, MRIs, and bone scans are painless tests.

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Treatment

As your arthritis progresses and becomes more severe, medication, rest, and physical therapy may fail to relieve your symptoms. Your pain and immobility may cause you to limit your activities and lifestyle. Hip replacement surgery is recommended when non-surgical treatments do not provide relief of your symptoms. Minimally invasive hip replacement surgery allows for faster recovery and less trauma to the body than standard hip replacement surgery.

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Surgery

Minimally Invasive Hip Arthroplasty is an alternative to traditional total hip replacement surgery. People who are smaller in size, younger, and healthy are the most appropriate candidates for this procedure, however doctors are performing it on a variety of patients. Minimally Invasive Hip Arthroplasty is similar to traditional total hip replacement in that it involves removing the damaged joint and replacing it with an artificial one. However, because the minimally invasive procedure utilizes one or more small incisions, the recovery process is much easier. 

Minimally Invasive Hip Arthroplasty is most often performed as an inpatient procedure, although in some cases it can be an outpatient surgery. The most common types of anesthesia for the surgery are general anesthesia or spinal anesthesia. The general anesthesia will put you to sleep. The spinal anesthesia will numb your body from the waist down, while you remain awake but sedated. Your doctor will help you decide which anesthesia is best for you.

Minimally Invasive Hip Arthroplasty may use a single or a double hip incision surgical method. With the single incision method, a three to six inch incision is made over the outside of the hip. The double incision method involves making a two to three inch incision over the groin and a one to two inch incision over the buttock. Your hip joint will be opened to allow your surgeon to remove damaged bone, cartilage, or connective tissue. The femoral head and the cartilage or bone from the hip socket will be removed. Your hip joint will be replaced with an artificial joint. There are a variety of prosthetics, and your surgeon will choose the most appropriate one for you. A highly polished strong metal ball will be implanted or attached to the top of your femur. A durable socket made of plastic or plastic and metal will be attached to your bone with surgical screws or surgical cement. The artificial joint will allow you to perform most of the pain-free movements that you used to be able to do.

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Recovery

Your hospital stay may be as short as one to two days following your Minimally Invasive Hip Arthroplasty. Some people may even go home on the day of the surgery. Because only small incisions are used, you can expect less pain, less muscle involvement, and a faster period of rehabilitation than with traditional surgery.

Your physician will temporarily restrict certain movements to prevent your artificial joint from dislocating. You should refrain from crossing your legs, bending your hips at more than a 90-degree angle, and pointing your feet inward or outwards. At first, you will need to use a walker, crutches, or cane while standing and walking. 

Your physical therapist will help you with walking and show you how to go up and down stairs. You will also learn exercises to strengthen your hip. An occupational therapist can show you ways to dress and bathe within the range of your movement restrictions. Your therapists can also recommend durable medical equipment for your home, such as a raised toilet seat or a shower chair. The equipment may make it easier for you to take care of yourself as you heal and help to prevent further injury.

You may need help from another person during the first few days at home. If you do not have family members or friends nearby, ask your doctor about possible alternative arrangements. 

Compared to traditional surgery, Minimally Invasive Hip Arthroplasty is associated with less blood loss, lower risks of infection, less pain, shorter hospital stays, and a shorter recovery time. You can also plan on being active sooner. You may be able to return to your normal activity level within four to six weeks, instead of the three to four month recovery period that usually follows traditional surgery. 

It is important that you follow your exercise program and adhere to safety precautions. You may resume many of your former activities following your Hip Arthroplasty. You may have to change the way you do some activities, such as bending, to protect your new hip. You will be advised to avoid high-impact sports, such as jogging, for the rest of your life. High-impact sports or weight gain can put stress on your artificial joint, causing it to become loose or wear faster. 

It is important to avoid falling. Your therapists can suggest ways to prevent falls in your home. This may simply mean removing throw rugs and making sure that your walking path is free of cords and clutter. You should also continue to use the durable medical equipment as advised.

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Introduction

Knee Replacement Surgery is the most common type of joint replacement surgery. The knee is one of the most easily injured joints. Knee problems can occur from injury, aging, “wear and tear,” and arthritis.

Arthritis is a disease that causes joint pain, stiffness, and swelling. It can affect the cartilage in the knee joint. Cartilage is a very tough, shock absorbing material that covers the ends of many of our bones. The cartilage forms a smooth surface and allows the bones in our joints to glide easily during motion. Arthritis can cause the cartilage to wear away. Loss of the protective lining can cause painful bone on bone rubbing. 

While the symptoms of knee arthritis may be tolerated with some medications and lifestyle adjustments, for many, knee replacement is the only way to reduce pain, restore function, and improve the quality of life. One type of knee replacement surgery is called Minimally Invasive Knee Arthroplasty. Like traditional total knee replacement surgery, it involves removing the damaged portion of the knee and replacing it with artificial implants called prosthetics. However, Minimally Invasive Knee Arthroplasty uses smaller incisions than traditional surgery. This allows individuals to experience less pain, spend less time in the hospital, and have shorter recovery times.

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Anatomy

The knee is the largest and most structurally complex joint in our body. Our knee is composed of three bones. The femur, or thighbone, is positioned on top of the tibia, the larger leg bone. The patella, or kneecap, glides in a groove on the end of the femur. 

Ligaments connect our knee bones together. Ligaments are strong tissues that provide structure and motion. Large muscle groups in our thigh give the knee strength and stability.

Two cartilage disks, called menisci, are located on the end of the tibia. The cartilage forms a smooth surface and allows our bones to glide easily during motion. The menisci also act as a shock absorber when we walk or run. 

A smooth tissue capsule covers the bones in our knee joint. A thin synovial membrane lines the capsule. The synovium secretes a thick liquid called synovial fluid. The synovial fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions.

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Causes

Arthritis is the most common cause of knee pain, stiffness, and swelling. Arthritis can occur for many reasons, including aging, “wear and tear,” injury, disease, and developmental abnormalities in the knee structure. There are over 100 different types of arthritis. Osteoarthritis, Post-Traumatic Arthritis, and Rheumatoid Arthritis are types of arthritis that frequently develop in the knee.

Osteoarthritis is the most common type of arthritis, affecting some 21 million Americans alone. It tends to develop as people grow older. Osteoarthritis can result from overuse of the knee during sports or work. Osteoarthritis causes the articular cartilage covering the end of the bones to gradually wear away, resulting in painful bone on bone rubbing and disrupted movement. 

Rheumatoid Arthritis is one of the most serious and disabling types of arthritis. Rheumatoid Arthritis can affect people of all ages, but most frequently occurs in women and those over the age of 30. It is a long-lasting autoimmune disease that causes the synovial membrane to become inflamed. This damages the articular cartilage and leads to pain and stiffness. Post-Traumatic Arthritis can develop in individuals of all ages after a serious knee injury. A knee fracture or severe torn ligaments can damage the cartilage over time. This can cause knee pain and limit function.

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Symptoms

The main symptom of severe knee arthritis is pain. Your pain may occur while you are moving or resting. It may even keep you awake at night. Your knee may feel swollen, stiff, and unstable. It may look like it curves inward or outward, instead of being straight.

It may be difficult to move or bend your knee. Your knee pain may eventually limit your everyday activities, including walking, stair climbing, and getting in and out of chairs. Medications, rest, and physical therapy may provide relief from the pain of severe knee arthritis.

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Diagnosis

Your doctor can diagnose arthritis by conducting a physical examination. You will be asked about your medical history, symptoms, and level of pain. You may be asked to perform simple knee movements to help your doctor assess your muscle strength, joint motion, and knee alignment. Blood tests and other laboratory tests may identify what type of arthritis you have.

Your doctor will order X-rays to see the condition of your bones and to identify areas of arthritis. Sometimes the tissues that surround the knee joint or the condition of the bones do not show up on an X-ray. In this case, your doctor may order Magnetic Resonance Imaging (MRI) scans or a bone scan. An MRI is used to obtain more detailed images. A bone scan identifies the location of abnormal growths in a bone, such as arthritis. A bone scan requires that you receive a small harmless injection of a radioactive substance several hours before your test. The substance collects in your bones in areas where the bone is breaking down or repairing itself. X-rays, MRIs, and bone scans are painless.

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Treatment

As your arthritis progresses and becomes more severe, medications, rest, and physical therapy may fail to relieve your symptoms. Your pain and immobility may cause you to limit your activities and lifestyle. Knee replacement surgery is recommended when non-surgical treatments do not provide relief of your symptoms, and the minimally invasive knee replacement provides shorter recovery times and less trauma to the body.

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Surgery

Minimally Invasive Knee Arthroplasty is an alternative to traditional total knee replacement surgery for some people. Minimally Invasive Knee Arthroplasty is similar to traditional total knee replacement in that it involves removing your damaged joint and replacing it with an artificial one. The minimally invasive procedure uses a three to six inch incision, which is much smaller than the traditional eight to twelve inch incision. Because of the smaller incision, Minimally Invasive Knee Arthroplasty is associated with a shorter hospital stay, an easier recovery, and a smaller scar.

Minimally Invasive Knee Arthroplasty is usually an inpatient procedure. The most common types of anesthesia for the surgery are general anesthesia or spinal anesthesia. The general anesthesia will put you to sleep for the procedure. The spinal anesthesia will numb your body from the waist down, while you remain awake but sedated. Your doctor will help you decide which anesthesia is best for you.

Your knee will be placed in a bent position for your surgery. Your surgeon will make a small incision on the side of your patella (kneecap). Your patella and thigh muscles will be moved aside to allow your surgeon access to your joint. Your surgeon will remove your damaged bone, cartilage, and connective tissue. Your knee joint will be replaced with an artificial joint. 

There are over 150 types of artificial knee joints. Your surgeon will choose the most appropriate one for you, depending on your age, weight, activity level, and overall health. Nearly all of them consist of three components. The new piece for the end of your femur is made of highly polished metal. The tibial component, for the top of your leg, is made of metal and plastic. The patellar part is made of plastic and fits inside of your kneecap. The artificial pieces may be implanted or surgically cemented in place. The artificial joint will allow you to perform most of the pain-free movements that you used to be able to do.

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Recovery

You may stay in the hospital for a few days following your Knee Arthroplasty. You will receive pain medication to make you feel as comfortable as possible. Your doctor may use several methods to prevent blood clots and swelling. 

Your doctor may prescribe blood thinning medication and special support stockings. You should keep your leg elevated and move or pump your foot and ankle. Your doctor may prescribe compression boots and a Continuous Passive Motion (CPM) Machine. Compression boots are inflatable leg coverings that are attached to a machine. They work to gently squeeze your legs to aid blood circulation. A Continuous Passive Motion (CPM) Machine will move your leg in a cycling motion while you are in bed. The CPM Machine is helpful to improve circulation, decrease swelling, and restore movement in your knee. 

Walking and knee movements are very important to your recovery. Exercising will begin immediately after your surgery. You will probably begin physical therapy the day after your surgery. At first, you will need to use a walker or crutches while standing and walking. Your physical therapist will help you with walking and show you how to go up and down stairs. You will also learn exercises to strengthen your knee. 

An occupational therapist can show you ways to dress and bathe within the range of your movement restrictions. Your therapists can also recommend durable medical equipment for your home, such as a raised toilet seat or a shower chair. The equipment may make it easier for you to take care of yourself as you heal and help to prevent further injury.

The success of your surgery will depend, in part, on how well you follow your home care instructions during the first few weeks following surgery. You may need a little help from another person during the first few days at home. If you do not have family members or a friend nearby, talk to your physician about possible alternative arrangements. You should be able to resume most of your regular activities in three to six weeks after your procedure. Overall, the majority of people experience a dramatic reduction of knee pain and the ability to resume functional activities after Minimally Invasive Knee Arthroplasty.

It is important that you adhere to your exercise program and safety precautions when you return home. You should stay as active as possible, but remember not to overdo it. You should notice a steady improvement in your strength and endurance.

It is also important to avoid falling. Your therapists can suggest ways to prevent falls in your home. This may simply mean removing throw rugs and making sure that your walking path is free of cords or clutter. You should also continue to use the durable medical equipment as advised.

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Introduction

In the past, spinal fusion surgery meant large incisions, muscle detachment and lengthy recoveries.  Innovations in spine surgery instruments and surgical techniques provide a much more pleasant experience for patients requiring spine surgery.  Minimally invasive lateral access spine surgery (lateral transpsoas approach) uses small incisions, a muscle sparing approach, and requires only a one or two day hospital stay.  In fact, people that have minimally invasive lateral access spine surgery can walk within a few hours of their surgery.

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Anatomy

The spine is composed of a series of bones called vertebrae.  There are different areas of the spine, defined by their curvature and function.  The seven small vertebrae in the neck make up the cervical spine.  The chest area contains the thoracic spine, with 12 vertebrae.  The lumbar spine is located at and below your waist.  The lumbar spine contains five large vertebrae.  The remainder of the lower vertebrae in the spine are fused or shaped differently in formation with the hip and pelvis bones.

The back part of each vertebra arches to form the lamina.  The lamina creates a roof-like cover over the back opening in each vertebra.  The opening in the center of each vertebra forms the spinal canal.  The spinal cord, nerves, and arteries travel through the protective spinal canal.  The spinal cord and nerves send messages between your body and brain.

Intervertebral discs are located between the cervical, thoracic, and lumbar vertebrae.  Strong connective tissue forms the discs.  Their tough outer layer is the annulus fibrosus.  Their gel-like center is the nucleus pulposus.  A healthy disc contains about 80% water.

The discs and two small spinal facet joints connect one vertebra to the next.  The discs and joints allow movement and provide stability.  The discs also act as a shock-absorbing cushion to protect the vertebrae.

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Causes

Minimally invasive lateral access spine surgery can be an alternative to traditional spinal fusion for select people with degenerative disc disease, recurrent disc herniation, spinal instability, spondylolisthesis, failed fusion, osteomyelitis (bone infection), discitis (disc infection), tumors, scoliosis, and post-laminectomy syndrome.  Surgical candidates have experienced significant back pain with or without leg pain, and have not had pain relief with medications, steroid injections, or physical therapy.

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Symptoms

People with low back pain or back pain that spreads to the legs may be candidates for minimally invasive lateral technique for spinal fusion.

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Treatment

Minimally invasive lateral technique spinal fusion surgery is an inpatient hospital procedure that typically requires a one or two day hospital stay.  The surgical approach is from the side of the person, rather than from the more traditional front or back approaches.  The surgeon uses real-time nerve localizing and monitoring technology, as well as X-ray guidance during the procedure. 

First, the surgeon makes a small incision on the side flank.  Dilators that provide electromyographic (EMG) data navigate the surgeon towards the spine.  Retractors gently spread the muscles to access the spine.

Once the appropriate area of the spine is reached, the required surgery can be performed.  Finally, the retractors are removed, and the incisions are closed.

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Recovery

Because only a small incision is required and muscles are spared, recovery from minimally invasive lateral technique spine surgery is much faster and less painful than with traditional spinal surgery methods.  Patients are able to walk within hours of spine surgery, and only a short hospital stay is needed.

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Introduction

Morton’s Neuroma is a painful foot condition.  It occurs when a nerve near the toes becomes compressed and inflamed.  If diagnosed early, most cases of Morton’s Neuroma can be treated without surgery.  However, surgery for the condition has a high success rate.

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Anatomy

In medical terms, your toes are called digits.  They are numbered one through five.  The big toe is the first digit, and  your little toe is the fifth digit.  Nerves travel through your foot to your toes to control movement and sensation. 

Morton’s Neuroma develops most often between the third and fourth digits of the foot.  This is the area where two nerves join together and become thicker.  A ligament (deep transverse metatarsal ligament) holds the bones in the foot together and covers the nerve.  Symptoms occur when the nerve is compressed between the ligament and the bottom of the foot.

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Causes

The exact cause of Morton’s Neuroma is unknown.  It results when the tissue surrounding the nerve between the third and fourth toes thickens, swells, and puts pressure on the nerve.  Inflammation then develops.

People with bunions, flat feet, and hammertoes are susceptible to developing Morton’s Neuroma. Pressure from standing, walking, jumping and running or wearing high heeled, pointed toe, or tight-fitting shoes can contribute to the condition.  High impact sports, such as racquetball, squash, or tennis, can lead to Morton’s Neuroma.

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Symptoms

Morton’s Neuroma can cause sharp pain, tingling, numbness, stinging, and burning between the third and fourth toes and the ball of the foot.  It may feel as if a lump is inside the ball of your foot or that you have stepped on a bump.  Your symptoms may be worse when you stand, walk, or put weight on your foot.  Symptoms typically start gradually, come and go, and become worse over time. 

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Diagnosis

You should contact your doctor if you have the symptoms of Morton’s Neuroma.  Early treatment can help avoid future surgery.  Your doctor can diagnose Morton’s Neuroma by reviewing your medical history, examining your foot, and taking x-rays. 

Your doctor will feel your foot to determine if there are any bumps or masses, and to pinpoint the symptoms.  X-rays may be used to rule out other conditions, such as a fracture or arthritis.  A magnetic resonance imaging (MRI) scan may be used to learn more about the size and location of the neuroma. 

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Treatment

There are a variety of treatments for mild to moderate Morton’s Neuroma.  The treatment you receive will depend on the severity of your symptoms.  Rest, wearing appropriate shoes, and over-the-counter pain medications, such as ibuprofen, can help reduce swelling and pain.  Padding or shoe orthotics can help reduce pressure.

If conservative treatments do not provide relief, your doctor may inject your foot.  Corticosteroid medication is used to reduce pain and inflammation.  Alcohol sclerosing injections are used to harden the nerve area and relieve pain.

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Surgery

Surgery may be recommended when other treatments do not provide symptom relief.  There are a couple surgical options for Morton’s Neuroma, release surgery and removal surgery.  Release surgery involves making an incision on the top of the foot to access the deep transverse metatarsal ligament that covers the nerve.  By making an incision in the ligament, the pressure is released from the nerve.

Removal surgery is performed through the bottom of the foot.   The neuroma is easier to access this way.  The neuroma is surgically removed, and the incision is closed with stitches. 

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Recovery

Recovery from surgery depends on the procedure that you received.  Because release surgery is performed from the top of the foot, there are no stitches on the bottom of the foot and walking may be resumed soon after the procedure.  Because removal surgery uses stitches on the bottom of the foot, you may need to use crutches for a time after surgery.  No matter what surgical or nonsurgical treatment you receive, healing is an individualized process, and your doctor will let you know what to expect.

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Prevention

Contact your doctor if you suspect that you have Morton’s Neuroma.  Early diagnosis and treatment can help avoid future surgery.  You may help prevent Morton’s Neuroma by modifying your activities to reduce high-pressure repetitive forces to your feet.  Wear low heel shoes with wide toe boxes, padding, and orthotics as recommended by your doctor.

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Introduction

The neck is a very vulnerable part of the spine.  It is susceptible to injury.  Muscle, ligament, nerve, and spine injuries are common causes of neck pain.  Poor posture and “wear and tear” can also cause neck pain.  Degenerative diseases, such as arthritis, can cause the spinal structures to break down and put pressure on the spinal cord or nerves. 

Neck pain can spread to the head, shoulders, arms, and hands.  It can be acute or chronic.  Acute neck pain begins suddenly, usually after an injury.  Acute neck pain resolves as the injury heals, usually within several days or weeks.  Chronic neck pain lasts longer than three months.  Chronic pain may be constant and caused by structural changes in the spine from degenerative diseases.

A medical examination is necessary to identify the cause of the neck pain and to determine the appropriate course of treatment.  Neck pain is usually treated with non-surgical methods.  However, if symptoms progress or continue, there are a variety of spinal surgeries to relieve neck pain.

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Anatomy

The spine is divided into regions that are defined by their curvature and function.  The cervical spine is located in your neck.  The cervical spine supports your head and connects it to your trunk.  The cervical spine supports less weight than any other portion of the spine.  It also has the greatest amount of mobility and flexibility.  Your neck can bend forward and backward or tilt from side to side.  Your neck can also turn or rotate to the right and left, a motion used when checking for traffic before crossing a street.
 
Seven small vertebrae make up the cervical area of your spine.  Vertebrae are the series of small bones that align to form the spine.  The back part of the vertebra arches to form the lamina.  The lamina creates a roof-like cover over the back opening in each vertebra.  The opening in the center of each vertebra forms the spinal canal.  
 
Your spinal cord, spinal nerves that travel to your arms and hands, and arteries that supply blood travel through the protective cervical spinal canal.  The top section of the cervical spinal canal is very spacious.  It allows more room for the spinal cord than any other part of the spine.  The extra space helps to prevent pressure on the spinal cord when you move your neck.
 
Intervertebral discs are located between the vertebrae in your cervical spine.  The discs are made of strong connective tissue.  Their tough outer layer is called the annulus fibrosus.  Their gel-like center is called the nucleus pulposus.  The discs and two small spinal facet joints connect one vertebra to the next.  The discs and joints allow movement and provide stability.  The discs also act as a shock-absorbing cushion to protect the cervical vertebrae.

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Causes

Neck pain is caused by abnormalities in the soft tissues, nerves, discs, or vertebrae of the neck.  The soft tissues--muscles, tendons, and ligaments, can strain from over exertion, poor posture, physical stress, and injury.  Motor vehicle crashes, sports, falls, or violence are causes of neck injuries.  Soft tissue injuries can cause painful muscle spasms or tightening of the neck muscles.
 
The spinal cord or spinal nerves cause neck pain when they are compressed, pinched, or irritated.  This commonly occurs from structural changes in the spine.  Bone spurs, abnormal bone overgrowths caused by Osteoarthritis, can grow in to the spinal canal or nerve root openings on the vertebrae.  Bone spurs can also contribute to a condition in which the spinal canal is narrowed, called Spinal Stenosis.  Some degenerative diseases can cause the spinal structures to thicken and extend into the spinal canal over time.  The narrowed canal causes pressure on the spinal cord and nerves, resulting in pain.
 
Changes in the intervertebral discs can also cause neck pain.  As we age, our discs lose water content.  Our discs become shorter and less flexible, a condition called Degenerative Disc Disease.  Once the discs are injured, they do not have the blood supply to repair themselves and they deteriorate.  Without the protective disc, the spine can become structurally unstable and unable to tolerate stress.  Degenerative Disc disease can also lead to a herniated disc.  
 
A herniated disc occurs when the outer disc layer, the annulus, ruptures.  When the inner content, the nucleus pulposus, comes out of the disc, it can cause pressure on the nerve tissue.  When the inner contents of the disc come in contact with the spinal nerves, a chemical reaction occurs that causes irritation, swelling, and pain. 
 
Osteoarthritis and Rheumatoid Arthritis are degenerative diseases that cause changes in the discs and vertebrae.  Normally, the discs act as a cushion between the vertebrae.  Without the disc functioning well, pain can occur. Spondylosis is a condition that results when Osteoarthritis or a fracture causes disc degeneration and the overgrowth of bone.  Spondylosis causes stiff and painful joints.  Spondylolisthesis is a condition that results when a weakened vertebrae slips out of alignment on the spine.
 
Osteoporosis is a medical condition that can cause the cervical vertebrae to weaken.  Osteoporosis causes more bone calcium to be absorbed than is replaced.  Bone calcium is necessary to keep your bones strong.  The weakened bones are susceptible to multiple fractures.  Osteoporosis can cause the cervical spine to curve, resulting in hunched posture and neck pain.

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Symptoms

The type of pain that you feel depends on the cause of your neck pain.  Your pain may range from mild to severe.  The pain may begin suddenly and gradually get better, or it may start gradually and persist over time.  The pain may spread to your head, shoulders, arms, and hands.  You may get headaches.  Your neck may feel stiff.  You may not be able to completely move your neck.  Your shoulder, arm, and hand muscles may feel weak.  You may also experience numbness or tingling in your forearm, hand, or fingers.
 
You should seek immediate medical attention if you experience severe neck pain following an injury, such as from a motor vehicle crash, diving accident, or fall.  You should not move your neck until it can be examined.  To avoid the risk of further injury or paralysis, a medical professional should immobilize your neck.  In rare cases, the loss of bowel and bladder control accompanied by significant arm and leg weakness indicates a serious problem.  If you experience these symptoms, you should also seek immediate medical attention.

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Diagnosis

Your doctor can determine the cause of your neck pain.  The cause must be identified in order to treat your symptoms appropriately.  Your doctor will perform a physical examination.  Your doctor will ask you about your symptoms and medical history.  You will be asked to perform simple neck movements to help your doctor assess your muscle strength, joint motion, and joint stability. Your doctor will test the reflexes and sensation in your arms and legs.  Your doctor may order lab studies to rule out disease processes that may affect your neck.  
 
Your doctor will order imaging studies to identify the location and source of your neck pain.  Your doctor will order X-rays to see the condition of the vertebrae in your cervical spine and to identify fractures, misalignment, narrowed discs, or damaged facet joints.  Sometimes doctors inject dye into the spinal column to enhance the X-ray images in a procedure called a myelogram.  A myelogram can indicate if there are pinched nerves, herniated discs, bone spurs, or tumors.  
 
A bone scan may be used to show fractures, tumors, infections, or arthritis.  A bone scan requires that you receive a small harmless injection of a radioactive substance several hours before your test.  The substance collects in your bones in areas where the vertebrae are breaking down or repairing.  
Your doctor may also order Computed Tomography (CT) scans, a Discogram, or Magnetic Resonance Imaging (MRI) scans to get a better view of your spinal structures.  CT scans provide a view in layers, like the slices that make up a loaf of bread.  The CT scan shows the shape and size of your spinal canal and the structures in and around it.  Your doctor may inject dye into the disc area to enhance the CT images in a procedure called a Discogram.  A Discogram provides a view of the internal structure of a disc and can help to identify if it is a source of pain.  The MRI scan is very sensitive.  It provides the most detailed images of the discs, ligaments, spinal cord, nerve roots, or tumors.  X-rays, myelograms, bone scans, CT scans, and MRI scans are painless procedures and simply require that you remain motionless while a camera takes the pictures.
 
Nerve conduction studies may reveal how your cervical spinal nerves are working.  Doctors commonly use a Nerve Conduction Velocity (NCV) test.  During the study, your spinal nerve is stimulated in one place and the amount of time it takes for the message or impulse to travel to a second place is measured.  Your doctor will place sticky patches with electrodes on your skin that covers the spinal nerve.  The NCV test may feel uncomfortable, but only during the time that the test is conducted.
 
An Electromyography (EMG) test is often done at the same time as the NCV test.  An EMG measures the impulses in the muscles to identify nerve and muscle problems.  Healthy muscles need impulses to perform movements.  Your doctor will place fine needles through your skin and into the muscles that the spinal nerve controls.  Your doctor will be able to determine the amount of impulses conducted when you contract your muscles.  The EMG may be uncomfortable, and your muscles may remain a bit sore following the test.

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Treatment

The treatment for neck pain depends on its cause, severity, and duration.  The majority of neck problems are treatable with pain medications, short periods of rest, and physical therapy.  You may wear a soft neck collar for support.
 
Over-the-counter medication or prescription medication may be used to reduce your pain.  If your symptoms do not improve significantly with these medications, your doctor may inject your neck with pain relieving medication.  Occupational or physical therapists can provide treatments to reduce your pain, muscle spasms, and swelling.  These include modalities, such as heat, ultrasound, and electrical stimulation.  The therapists will also show you exercises to gently stretch and strengthen your neck muscles.  Aquatic therapy may help ease your pain, relax your body, and provide support for you to exercise your joints.

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Surgery

Surgery is recommended when non-surgical methods have provided minimal or no improvement of your symptoms.  Surgery may be required if a herniated disc, bone spur, or a narrowed spinal canal is pressing directly on a nerve or the spinal cord.  Surgery may also be required to stabilize a fractured vertebra after traumatic injury.  The goals of neck surgery are to remove the pressure from the nerves or spinal cord and establish neck stability.  There are several options for surgery, depending on the cause of the neck pain.  Some of the more common surgeries are described below.
 
An Anterior Cervical Discectomy and Fusion is the type of surgery most frequently used for a herniated cervical disc.  An Anterior Cervical Discectomy and Fusion involves removing all or part of a herniated disc or discs.  The surgeon also fuses or secures two or more vertebrae together to stabilize the area.
 
Spinal Fusion is the type of surgery most frequently used for degenerative disc disease.  Spinal Fusion involves removing the degenerative disc from between the vertebrae.  The vertebrae are fused together to stop movement.  
 
The most common surgery for Spinal Stenosis is a Laminectomy.  The goal of this surgery is to relieve pressure on the spinal cord and nerves by enlarging the spinal canal where it has narrowed.  To do so, the surgeon removes all or part of the lamina on the affected vertebrae. 

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Recovery

Recovery from surgery depends on the cause of your neck pain and the type of surgery that was performed.  Most surgeries require at least an overnight stay in the hospital.  Your physician will let you know what to expect. 
 
Individuals usually participate in physical therapy following surgery.  Physical therapy exercises will help strengthen your neck muscles.  Overall, most individuals achieve good results with surgery and are able to resume their regular lifestyles.

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Prevention

It is important that you adhere to your restrictions and exercise program when you return home.  It is important to keep your muscles strong and flexible.  You should use proper posture when lifting, standing, sitting, and moving your body.
 
It can be helpful to maintain a healthy weight.  Do not smoke.  Smoking increases the risk of surgical complications and hinders bone fusing. 

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Introduction

Osgood-Schlatter Disease is actually a type of overuse injury and not a disease.  It affects the knees of growing children and adolescents who play sports that involve running or jumping.  The main symptoms of Osgood-Schlatter Disease are pain and swelling.  The vast majority of youth with Osgood-Schlatter Disease are treated successfully with non-surgical methods, and the condition rarely causes permanent orthopedic problems.

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Anatomy

The knee is composed of three bones.  The thighbone (femur), sits on the larger leg bone (tibia).  The kneecap (patella) glides in a groove on the end of the femur.  Osgood-Schlatter Disease affects the tendon below the attachment site of the patella tendon located on the tibia (anterior tibial tubercle).

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Causes

The exact cause of Osgood-Schlatter Disease is unknown, but researchers suspect it results from a series of microfractures over time.  Osgood-Schlatter Disease develops in growing children between the ages of 10 and 15 who participate in sports that involve running or jumping.  It is more common among boys than girls. 

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Symptoms

The main symptoms of Osgood-Schlatter Disease are pain, swelling, and tenderness in the area below the kneecap.  The pain may increase when the knee is bent.

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Diagnosis

An orthopedic doctor can diagnose Osgood-Schlatter Disease by reviewing your child's medical history and examining his or her knee.  You should tell your doctor about sports or activities in which your child participates in that involve repetitive running or jumping.  X-rays will be ordered to rule out other causes of pain.

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Treatment

Most cases of Osgood-Schlatter Disease improve with rest, ice, and non-steroidal, anti-inflammatory medications (NSAIDS).  In rare cases, crutches and a cast or brace is used for about six to eight weeks.  In the majority of patients, Osgood-Schlatter Disease improves in a few weeks or months. 

The condition eventually goes away once a child has finished growing.  Individuals should be allowed to play sports as long as they do not have symptoms. Osgood-Schlatter Disease improves faster if activities are minimal.

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Surgery

It is very rare for Osgood-Schlatter Disease to require surgery.  A tibial sequestrectomy is used to remove structures on the knee (bursa, ossicle, prominence).  However, surgery on a growing bone is controversial.

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Introduction

Osteoarthritis is the most common type of arthritis, affecting more than 21 million Americans.  Osteoarthritis tends to develop as people get older or from overuse of the knee during work or sports.  Osteoarthritis causes the protective covering at the ends of the bones in the knee to gradually wear away, resulting in painful bone on bone rubbing and disrupted movement.  Medications, physical therapy, and knee injections are used to treat osteoarthritis of the knee.  Surgery may be necessary if pain and immobility limit your activities and lifestyle, despite non-surgical treatments.

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Anatomy

The knee is one of the most complex joints in the body.  It is composed of three bones.  The thighbone (femur) is positioned on top of the larger leg bone (tibia).  The kneecap (patella) glides in a groove on the end of the thighbone.  Large muscle groups in the thigh give the knee strength and stability. 

A smooth articular cartilage covers the bones in the knee joint.  The articular cartilage serves as a cushion between the joints, allowing the bones to glide pain-free during motion.  When the articular cartilage breaks down, the space between the joint narrows and becomes uneven.

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Causes

Osteoarthritis of the knee occurs as the articular cartilage in the knee joint breaks down, causing a reaction in the bone.  The bones in the knee joint become thicker and develop growths (osteophytes or spurs). Lubricating fluid in the joint (synovial fluid) gets thicker and inflamed. If too much fluid is produced, a condition referred to as "water on the knee" can result.

With osteoarthritis, the knee joint continues to experience changes over several years.  Eventually, very little of the articular cartilage remains.  Bone-on-bone rubbing causes pain, impairs knee movements, and makes daily activities difficult.

Factors that increase the risk of developing osteoarthritis include:
• Excess weight or obesity that adds pressure to the knee joints
• Heredity
• Increasing age
• Women more than 50 years old have a higher incidence than men
• Knee injury
• Repetitive stress injury to the knee
• Participation in high impact sports
• Certain illnesses, including septic arthritis and metabolic disorders

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Symptoms

Osteoarthritis of the knee can cause knee pain and swelling.  You may have difficulty moving your knee or performing activities such as walking, squatting, kneeling, and going up or down stairs.

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Diagnosis

Doctors diagnose osteoarthritis of the knee by examining the knee, considering your symptoms, and reviewing your medical records. X-rays are the main diagnostic tool to diagnose osteoarthritis.

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Treatment

Treatment of osteoarthritis of the knee is individualized.  The treatment that you receive depends on several factors, including your overall health and the stage of disease.  Osteoarthritis of the knee is treated with physical therapy, lifestyle changes, medications, surgery, or a combination of treatments. 

If you are overweight , your doctor may recommend that you lose weight.  Attaining and maintaining a healthy weight reduces the load on your knees.  Participating in physical therapy can help strengthen the muscle groups around the knee joint.  A knee brace can provide support.

Your doctor may recommend over-the-counter pain medications such as aspirin or nonsteroidal anti-inflammatory drugs.  Your doctor may prescribe stronger prescription pain medications if necessary.  Joint injections, such as corticosteroid injections or viscosupplementation, are used for osteoarthritis pain relief.

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Surgery

If symptoms persist despite conservative treatments, knee surgery may be necessary.  Osteotomy and joint replacement (arthroplasty) are surgical procedures to treat osteoarthritis of the knee.  Osteotomy is used to remove and reshape bone from the leg to cause a shift in body weight away from the damaged area. Casting, splinting, and physical therapy follow osteotomy.  Recovery from osteotomy varies from 3 to 6 months for some people, and up to a year for others.

Total knee replacement removes the damaged portion of the knee and replaces it with artificial implants.  Knee replacement is the most common type of joint replacement surgery.  It is highly successful for relieving pain and restoring function. Minimally invasive knee replacement surgery uses smaller incisions, and is associated with shorter hospital stays, shorter rehabilitation periods, and a quicker recovery time than traditional total knee replacement.  Your doctor will let you know which knee joint replacement method is best for you.  Overall, most people experience a dramatic reduction of knee pain and the ability to resume functional activities after knee arthroplasty.

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Introduction

Osteoporosis is the most common bone disease.  It causes progressive bone loss and increases the risk of fractures.  Osteoporosis is more common in women than men, and the incidence increases with age.  Bone loss from osteoporosis can lead to fractures and disability.  The progression of osteoporosis may be reduced with treatments, including dietary changes, nutrition supplements, exercise, and medications.

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Anatomy

Your bones vary in size and shape.  All of your bones line up and connect to form your skeleton.  In addition to creating your body structure, your bones produce blood cells, form joints with muscles for movement, and protect your internal organs. 

Your bones are live tissues.  They change and grow like the other parts of your body.  Most of the bones in your body are composed of the same layered materials. 

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Causes

Although the exact cause of osteoporosis is unknown, there are several factors that may contribute to the condition.  As you grow older, new bone production decreases, resulting in a reduced total bone mass.  People with small bones or a family history of fractures have a greater risk of developing osteoporosis.  The risk for women increases at menopause when estrogen levels drop.  Poor nutrition, a low calcium diet, smoking, excessive alcohol intake, and a lack of regular exercise are lifestyle factors that may contribute to osteoporosis.  Medications, such as steroids or anticonvulsants, and some illnesses, such as thyroid disorders or bone cancer, can cause osteoporosis.

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Symptoms

Osteoporosis does not cause symptoms in the early stages of the disease.  As osteoporosis progresses, you may experience bone tenderness or pain, particularly in your neck or low back.  You may develop stooped posture and a loss of height.  For many, bone fractures are the first sign of osteoporosis.  The spine, wrists, or hips are common fracture sites.

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Diagnosis

Your primary care physician or gynecologist may assess you for osteoporosis.  You should tell your doctor about your risk factors.  Bone mineral density (BMD) testing is an evaluation used to help diagnose osteoporosis.  It is a type of X-ray test called a dual-energy x-ray absorptiometry (DEXA).  BMD testing is recommended for women under the age of 65 with risk factors other than menopause, postmenopausal women with fractures, and all women age 65 and older.  Additional X-rays, computed tomography (CT) scans, blood tests, and urine tests may be used.

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Treatment

Lost bone cannot be replaced, but further bone loss can be prevented.  Treatments are also aimed at reducing pain and preventing fall-related fractures.  Your doctor will make nutrition and exercise recommendations for you.  Calcium and Vitamin D supplements are commonly advised.  Weight bearing exercises, such as walking, can help prevent bone loss and possibly increase bone density.  It is also helpful to reduce the risk factors that you can control, such as quitting smoking. 

There are several different types of medications that are used to treat osteoporosis.  Your doctor will review the risks and benefits of the medications with you.  Bisphosphonates and hormone replacement therapy are used to treat osteoporosis in postmenopausal women.  Newer anti-estrogen medications, such as Raloxifene, are selective estrogen receptor modulators (SERMs).  SERMs act similar to estrogen to increase bone density, reduce the risk of fractures, and lower the risk of breast cancer.  Calcitonin is a medication that eases pain and slows the bone loss process.  Alendronate is a newer FDA approved medication to help prevent bone loss from osteoporosis.

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Prevention

Osteoporosis cannot be cured, but its progression may be prevented with medication, diet, and exercise.  You should reduce the risk factors that you can control, such as not smoking or drinking alcohol excessively. 

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Am I at Risk

More women than men develop osteoporosis.  The condition is more common in people that are Caucasian or Asian.  Risk factors may increase your chance of developing osteoporosis.  Risk factors include:

_____ Increasing age is a risk factor for osteoporosis.  With aging, calcium and phosphate substances that make bones strong, are reabsorbed by the body causing bones to become weaker.
_____ Decreased estrogen levels in women after menopause increases the risk of osteoporosis.
_____ Lowered testosterone levels in men with aging increases the risk of osteoporosis.
_____ Excess corticosteroid production from Cushing’s syndrome, hyperthyroidism, and hyperparathyroidism increases the risk of osteoporosis.
_____ Bone cancer may cause osteoporosis.
_____ Immobility or being confined to a bed may increase the risk of developing osteoporosis.
_____ Osteopenia, abnormally low bone density, may lead to osteoporosis.
_____ People with a family history of osteoporosis have a greater risk of developing osteoporosis.
_____ Certain medications, such as steroids and anticonvulsants, can cause osteoporosis.
_____ Absent menstrual periods (amenorrhea) or early menopause may increase the risk of osteoporosis.
_____ Smoking and heavy alcohol consumption increases the risk of osteoporosis.
_____ Eating disorders and low body weight increase the risk of osteoporosis.
_____ A lack of calcium in your diet increases the risk of osteoporosis.

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Complications

Bone loss from osteoporosis can lead to fractures, particularly in the spine, wrist, and hips.  Hip fractures are a leading cause of admittance to nursing homes.

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Advancements

Researchers are working on developing a urine test to diagnose early osteoporosis.  This may expedite treatment and help to reduce the effects of osteoporosis.

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Introduction

Viscosupplementation therapy is a treatment for knee osteoarthritis.  Osteoarthritis is a common type of arthritis that causes bone degeneration and synovial fluid reduction.  Synovial fluid acts as a shock absorber and lubricant in the knee joint.  Arthritis and a decrease in synovial fluid can cause knee pain, stiffness, and problems with walking or stair climbing.

Viscosupplementation therapy is an appropriate treatment for people with moderate to moderately severe knee osteoarthritis that has failed to respond to traditional treatments.  It is useful for people that are trying to delay or are not candidates for knee replacement surgery.  Viscosupplementation therapy uses a product called hyaluronic acid (HA) to supplement the synovial fluid.

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Treatment

Your doctor can administer Viscosupplementation therapy in his or her office.  Your doctor will inject HA into your knee joint.  You will receive a series of three to five injections given on a schedule of one per week.  The time it takes for beneficial effects to be felt is variable.  The extent of pain relief also varies from patient to patient.  Good results can be sustained for 6-12 months.

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Introduction

Your knee is an important joint that supports the weight of your body and must function correctly for movement and walking. Your knee is made from bone, ligaments and cartilage. One type of cartilage covers the bones, and the other type cushions between the bones.

The knee is the most commonly injured joint in the body. Injuries to the knee are not always just to the bones, but also the ligaments, tendons or cartilage.  Your knees can be injured or affected by some kind of arthritis. The most common causes of knee injury include sports and accidents.

Symptoms of a knee injury or problem include pain, inability to put weight on your knee, stiffness, instability and swelling and even bruising if an injury happened suddenly.

When an injury or arthritis affects only one part of the knee, your doctor may talk to you about a partial knee replacement.  Your doctor may offer this procedure only after other treatments (injections, medication, and physical therapy) have not worked. This is a good option for patients who have arthritis in just one part of the knee, or who have a joint problem that is only in one section (compartment) of the knee.

During the surgery, your doctor will remove only the bone and tissue that needs to be taken out and replace it with metal and plastic parts. The rest of the healthy tissue and bone is left alone.

Many people who have a partial knee replacement do very well afterward and have a shorter healing time, lose less blood during surgery, and have less pain than  patients who have a total knee replacement.

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Anatomy

Your knee is a hinge joint that joins the thighbone (femur) with the shinbone (tibia). There is a smaller bone that runs beside the shinbone (fibula) and the kneecap at the front of your knee. Surrounding these bones and connecting all around them are strap-like tissues called ligaments that keep the knee steady, connecting the bones to each other, and tendons that attach the muscles to the bones.

• The ACL (anterior cruciate ligament) keeps the shinbone from sliding forward on the thighbone.
• The PCL (posterior cruciate ligament) keeps the shinbone from sliding backward on the thighbone.
• Other ligaments on either side of the knee (medial and lateral collateral ligaments) keep the bones from shifting from side to side.

Where the shinbone and thighbone meets are two cushions made from cartilage (medial and lateral meniscus). Shaped like the letter “C” this cartilage provides shock absorption and keeps the two bones from rubbing together. There are also several sacs inside the joint that provide lubrication for movement. These are called bursae.

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Causes

Osteoarthritis

Osteoarthritis is the most common type of arthritis affecting about 21 million Americans. It tends to develop as people grow older. Osteoarthritis can result from overuse of a joint during sports or work.

The most common reason you may need a partial knee replacement is arthritis (osteoarthritis). Arthritis causes swelling and damage around the padding in the knee (cartilage) , causing it to wear away. As the bones begin to rub against one another, abnormal bone growths, called spurs, can grow around the joint. The bone spurs add to pain and swelling, while disrupting movement.

Osteoarthritis usually happens slowly, and may take years to get bad enough for you to need a partial knee replacement.

Other problems

Some patients may need a partial knee replacement years after an old injury, like a car accident or another type of old injury to the cartilage or ligaments. Patients with rheumatoid arthritis are not candidates for a partial knee replacement because it is a disease of the whole joint and this procedure just treats one area.

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Symptoms

Most patients who get arthritis in their knees are over age 50 but it can occur in patient who are younger, although this is rare. Just because you do not meet typical age requirements does not mean you should not have your knee pain checked. Other symptoms of arthritis usually happen in adults who are overweight, and some doctors think that there may be a genetic link as well. This could mean that if your mother, father or siblings have had a knee replacement, there may be a higher chance that you will need one.

The most common arthritis symptoms you may notice include:

• Pain
• Swelling
• Stiffness
• Feeling like your knees are going to “give out” or collapse
• Tenderness around the knee
• Symptoms may fluctuate with the weather
• You may experience good and bad days with knee pain

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Diagnosis

To diagnose the cause of your knee problems, your doctor will take a history. Try to make a note of any injuries you have had to your knees and when. If you cannot remember, ask a family member, or take along a friend or loved one with you who can help you. Next, the doctor will examine your knee and watch you walk.

You will need an X-ray of your knee. This will show the doctor if the space between your thigh and shinbones has gotten smaller. (This is because the cartilage or padding is worn away and not taking up as much space as it used to). To make sure you do not have rheumatoid arthritis, your doctor may do blood tests, or test fluid from your joint if it is swollen.

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Treatment

Non-surgical treatment

If you are considering a partial knee replacement, you have probably tried non-surgical treatments. If you have not, your doctor will want you to start with those. He or she may suggest losing weight, adjusting your exercise routine, supportive braces, medication or physical therapy. There are injections that can be placed into the knee that can bring relief for weeks or months, allowing you to put off the surgery.

Surgical treatment

Surgical treatment will involve replacing the worn cartilage with metal or plastic replacement parts. To do the surgery, your doctor will replace the area of arthritis with a metal cap and put in a plastic liner. This will let the metal and plastic move smoothly like your old knee should have; and without the arthritis and painful tissue in your knee, you will be able to move and enjoy activities again.

Your doctor will closely examine your X-rays to determine where your arthritis is most severe and decide if you are a good candidate for a partial replacement. If you have very advanced arthritis, you will not be a good candidate for a partial replacement and will need a total knee replacement. Your doctor will help you make the right decision.

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Surgery

On the day of surgery, your doctor will give you specific instructions, and you may be admitted to the hospital. Many doctors are doing partial knee replacements as an outpatient procedure now. This means you can go to a surgical center or hospital’s same day surgery department for your procedure and go home the same day. Your doctor will decide if you need an overnight hospital stay or if you will be able to go home after your procedure.

Before your surgery, the doctor in charge of controlling your pain during surgery(anesthesiologist) will come in to see you. He or she will examine you and take a medical and anesthesia history. Some doctors will do a partial knee replacement while you are awake, but numb from the waist down. This is called spinal anesthesia or an epidural. Other physicians or patients choose to be asleep for the surgery (general anesthesia). If you decide you want to be asleep, that is okay.

Your doctor will also stop in to see you before surgery and sign your knee. This helps operating room staff know which knee to clean and prepare, and ensures the correct knee is operated on.

Once you are asleep, a partial knee replacement usually takes 1-2 hours. During the procedure, your doctor makes a cut down the front of your knee and will confirm that the arthritis is not in more than one area. If it is, he or she may do a total knee replacement instead. Do not worry though—this won’t be a surprise because your doctor will have talked about this with you before surgery, and you must give permission and sign a consent for the procedure, just in case.

If everything looks good for the partial knee replacement, your doctor will use a special saw to cut away the damaged bone and cartilage from your knee and will cap the bones that have been rubbing against each other with a thin pieces of smooth metal that are usually cemented into place. Your new plastic padding is then fitted between the metal caps and secured in place.

After surgery, you will spend about an hour in the recovery area and then either be moved to a hospital room or out to your same-day surgery room and prepare to go home.

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Recovery

Because a partial knee replacement is done through a smaller incision and with less damage to other parts of the knee, you will recover faster than patients who have a total knee replacement. Most patients are able to put weight on their knee right after surgery but you may need a walker, cane or crutches to help you until you feel steady and strong enough to walk without it.

Your doctor may recommend that you begin physical therapy, or may give you some activities to do at home to help your knee movement and flexibility. You shouldn’t begin any exercise routines or vigorous activity until your doctor says it is okay. He or she will also want to see you for follow-up appointments at regular intervals and will tell you when you can start doing normal activities again.

Every situation will vary, but most patients experience a steady recovery and are able to drive or return to work in a few weeks. You will be advised to avoid high-impact activities (like running), and will have to adjust routines to accommodate your knee replacement and ensure that it works for many years to come.

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Complications

Every surgical procedure has some type of risk, and your doctor will talk with you about these risks before surgery. Problems after partial knee replacement can include:

• Blood clots: Some patients can develop a blood clot in the veins deep in the leg. Blood thinners are used to prevent this.
• Infection: Any time you have surgery, there is a chance that the area of the surgery could get infected. Your doctor will start you on antibiotics before your surgery, typically given by IV right before your surgery begins.
• Continued pain or nerve damage. Although rare, sometimes nerves are stretched or damaged during your procedure. These nerves may never fully recover. There is also a chance that your pain may not go away completely. Of course, you will have pain for a period of time after your surgery, but long-term pain does not usually continue.

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Introduction

The patellar tendon connects the kneecap to the leg.  During sports that involve running or jumping or because of tendonitis, certain medical conditions, or steroid use, the tendon can tear.  Small partial tears may heal with non-surgical treatment; however, most patellar tendon tears require surgery followed by physical therapy rehabilitation.

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Anatomy

The knee is composed of three bones.  The thighbone (femur), sits on the larger leg bone (tibia).  The kneecap (patella) glides in a groove on the end of the femur.  The upper portion of the patellar tendon attaches at the lower side of the kneecap.  The lower portion attaches near the top of the tibia (anterior tibial tubercle). Tendons are strong tissues that connect muscles to bones. The patellar tendon plays a role in holding the kneecap in place and straightening the knee.

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Causes

The patellar tendon can tear completely or partially.  Complete patellar tendon tears tend to detach at the kneecap.  Such injuries occur from a strong impact to the knee or during sports that require running or jumping. 

Partial tendon tears usually occur in the middle of the tendon, because of patellar tendonitis, chronic disease, or steroid use.  Weak or inflamed tendons are more likely to tear.  Patella tendon tears happen more often in middle-aged people. 

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Symptoms

You may have a popping sensation when the patellar tendon tears, followed by pain and swelling.  Your kneecap may appear higher than usual.  Other symptoms of a patellar tendon tear include: 

• Knee Bruising
• Knee Cramping
• Knee Buckling
• Difficulty Walking
• Inability to Straighten the Knee

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Diagnosis

A doctor diagnoses a patellar tendon tear by reviewing your history, examining the knee, and conducting medical imaging tests.  Your doctor may order X-Rays or magnetic resonance imaging (MRI) scans to provide views of the knee bones and soft tissues to confirm the diagnosis. 

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Treatment

Orthopedic surgeons treat patellar tendon tears on a case-by-case basis.  The type of treatment that you receive depends on several factors, including your age and activity level, as well as the size and type of tendon tear.  Some very small tears are treated non-surgically.  You may wear a knee immobilizer and use crutches for three to six weeks.  A physical therapist will first teach you exercises to strengthen the muscles (quadriceps) that straighten the knee.  Your physical therapist will increase your exercise regime as you heal.

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Surgery

Most people with patellar tendon tears require surgery to reattach the tendon to the kneecap.  Surgery to repair a torn patellar tendon usually requires an overnight inpatient stay, although it may be performed as an outpatient surgery, depending on the circumstances.  Patellar tendon surgery is performed with regional (spinal) anesthesia or general anesthesia. 

To begin, the orthopedic surgeon makes an incision over the kneecap.  The patellar tendon is reattached to the kneecap with sutures or surgical hardware.  The surgeon carefully checks the kneecap position and tendon tension.

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Recovery

Your doctor will prescribe pain medication and recommend ice following surgery.  You will wear a brace or cast and use crutches at first, gradually increasing the amount of weight that you put on your foot. 

As you heal, physical therapists will teach you strengthening exercises.  You will gradually be able to bend your knee, per your doctor's instructions.  Complete recovery can take 6 to 12 months, depending on the extent of injury and surgery.

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Introduction

Patellofemoral Syndrome is pain in the knee that occurs from poorly aligned knee structures, trauma, or overuse.  It is also called runner’s knee and Chondromalacia patellae.  Patellofemoral syndrome results when the cartilage behind the kneecap is overstressed or deteriorates.

Patellofemoral Syndrome causes pain and loss of function.  It can be treated with rest, knee bracing, medications, and physical therapy.  In some cases surgery may be necessary to smooth damaged cartilage or realign the kneecap.

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Anatomy

The knee is one of the more complex joints in your body.  Three bones compose your knee.  The femur, your thighbone, is positioned on top of the tibia, your larger leg bone.  The patella, your kneecap, glides in a groove on the end of the femur.  Four main ligaments connect the knee bones together.  Large muscle groups in the thigh provide strength, stability, and motion. 

Cartilage located on the end of the bones and underneath the kneecap allows your bones to glide easily during movement.  The synovial membrane that covers the inside of your joint capsule secretes a fluid (synovial fluid) to lubricate the knee joint and nourish the cartilage.  The cartilage and synovial fluid act as a shock absorber when you walk or run. 

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Causes

Patellofemoral Syndrome occurs when the cartilage underneath the kneecap softens and degenerates.  This may occur because of overuse, abnormally aligned knee structures, or trauma.  Sports, such as skiing, cycling, running, and soccer are associated with Patellofemoral syndrome.  Arthritic changes in the kneecap can occur from chronic Patellofemoral syndrome.

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Symptoms

Patellofemoral syndrome can cause dull knee pain, swelling, and tenderness.  Your pain may increase after you have been seated for a long period of time or during certain activities, such as using stairs, kneeling, squatting, or getting out of a chair.  You may notice that your knee grinds when you straighten it.

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Diagnosis

Your doctor can diagnose Patellofemoral Syndrome by reviewing your medical history and examining your knee and entire leg.  X-rays will be taken to check knee alignment and to evaluate for arthritic changes.  In some cases, additional imaging tests may be ordered.  CAT scans and MRIs are often uses to evaluate the tracking of the patella and to better see the cartilage surfaces.

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Treatment

The goal of treatment is to relieve pain while restoring motion and function of the knee.  This may be achieved in several ways.  You should rest and avoid strenuous activities until your pain resolves.  A knee brace or custom-made shoe inserts can provide support during activities.  Your doctor may recommend ice packs or non-steroidal anti-inflammatory medications to relieve pain and swelling.  You will be referred to physical therapy for strengthening and flexibility exercises.

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Surgery

Surgery may be necessary to correct knee malalignments.  Realignment surgery is used to correct the position of the kneecap.  Arthroscopic surgery can be used to realign the patella in some cases, and to remove damaged cartilage. 

With arthroscopic technology, your surgeon will not need to open your joint.  Arthroscopic surgery uses an arthroscope and narrow surgical instruments that are inserted through small incisions.  An arthroscope contains a lens and lighting system that allow a surgeon to view inside of a joint.  The arthroscope is attached to a miniature camera.  The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.  Arthroscopic surgery is associated with shorter recovery times and less pain and bleeding than open procedures.
 
Sometimes the kneecap malalignment is not treatable arthroscopically, and in such cases there are open surgical techniques that are indicated.  Your doctor will discuss which type of surgery is best for your particular problem.

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Recovery

Recovery from Patellofemoral Syndrome is individualized and depends on many factors, including the cause and the treatment method you receive.  Your doctor will let you know what to expect.

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Introduction

Little League elbow, also called Pitcher’s elbow, results from excessive throwing motions used in sports.  It most frequently occurs in baseball, but is associated with other sports that involve throwing.  Pitcher’s elbow causes pain and interferes with motion.  Many cases of pitcher’s elbow respond to rest and nonoperative treatment.  If left untreated, Pitcher’s elbow can lead to significant problems that require surgery.

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Anatomy

The two bones in your child’s forearm, the ulna and radius, and your child’s upper arm bone, the humerus, form his or her elbow joints.  Muscles, nerves, tendons, and ligaments allow your child’s elbow joints to bend, straighten, and rotate.  Tendons are strong fibers that attach muscles to bones, and ligaments connect bones to each other.

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Causes

Pitcher’s elbow occurs in players that participate in sports that require repetitive throwing.  It most frequently affects pitchers, but may also develop in outfielders, catchers, and infielders.  Pitcher’s elbow is associated with other sports as well, including tennis and football. 

Pitcher’s elbow, also called Little League elbow because it occurs in children and teenagers that play sports, is especially concerning for this population because their bones are growing and injuries can affect the growth process.  Additionally, their skeletal systems may not be developed enough for the demands of competitive sports.

Pitcher’s elbow results when repetitive throwing puts an excessive strain on the tendons and ligaments in the elbow.  The strong movements can cause the ligaments and tendons to stretch, tear, or pull away from the bone.  If some of the bone is also torn away in the process, it can interfere with normal bone growth and cause deformity.  If the forces are great enough, the bones may slam together, causing the bones or cartilage to fracture, and resulting in a condition called osteochondrosis dissecans.

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Symptoms

Pitcher’s elbow causes pain on the inner side of the elbow.  Your child’s elbow joint may feel like it locks or gets stuck.  It may be difficult for your child to move the elbow as he or she did before, and it will affect your child’s pitching performance.

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Treatment

Your child should stop performing throwing activities and allow his or her elbow to rest if your child experiences pain.  Ice packs may help relieve pain and swelling.  Following rest, throwing should be returned to gradually.  Therapy can be helpful, and sometimes a review of your child’s pitching motion may be beneficial.  If your child’s pain persists or recurs with throwing activities, you should consult your doctor.

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Surgery

Arthroscopy can both diagnose and treat conditions associated with pitcher’s elbow.  Arthroscopic surgery uses an arthroscope and narrow surgical instruments that are inserted through small incisions.  An arthroscope contains a lens and lighting system that allow a surgeon to view inside of a joint.  A miniature camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.  Arthroscopic surgery is associated with shorter recovery times and less pain and bleeding than open procedures.  Following surgery, physical or occupational therapy is helpful for regaining mobility, strength, and function.

Arthroscopic surgery is not appropriate in every case, with some problems requiring open procedures.  Your doctor will discuss the type of surgery that is best for your child’s particular problem.

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Recovery

Recovery from pitcher’s elbow is different for everyone.  It depends on the extent of your child’s condition and the type of treatment that your child receives.  Most players can return to play when their rehabilitation is complete.  Your doctor will let you know what to expect.

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Prevention

Your child may prevent pitcher’s elbow by taking breaks from pitching, limiting his or her amount of throwing, and altering his or her throwing motion, if necessary.  Your child should be sure to warm-up before pitching.  Your child should exercise to keep his or her arm strong and flexible. 

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Introduction

Peripheral neuropathy is a symptom rather than a disease in itself.  It occurs when nerves are damaged resulting in pain and loss of function, such as motor movement or the sense of touch.  Peripheral neuropathy commonly develops in the longest nerves first, affecting the toes and feet.  Correcting the underlying cause of peripheral neuropathy, such as managing diabetes, can help resolve symptoms.  Physical or occupational therapy, medications, and lifestyle changes may be recommended as well.

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Anatomy

Your brain and the rest of the nervous system constantly exchange messages about your body.  Certain nerve pathways have specific tasks.  The motor nerves transmit signals about muscle movements.  The sensory nerves send signals about what you feel, such as heat, cold, pain, and touch.  Such functions as blood pressure, heart rate, digestion, and body temperature are automatic and controlled by the autonomic nervous system. 

Peripheral neuropathy typically begins in the ends of the longest nerves, such as the sensory nerves in the toes and feet.  However, peripheral neuropathy can affect other nervous systems, and the symptoms will depend on what functions the nerves control.  For example, if the autonomic nervous system is involved, bowel and bladder problems may be present.

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Causes

Peripheral neuropathy is caused by damage to one or several nerves.  There are many causes of nerve damage, and a primary cause is diabetes (diabetic neuropathy).  Other causes include trauma, disease, infection, alcoholism, vitamin deficiencies, chemotherapy, and toxins.

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Symptoms

The symptoms of peripheral neuropathy are directly related to the affected nerve and the functions of that nerve.  Peripheral neuropathy most frequently develops first in the longest nerves, such as those in the toes and feet, before the hands and arms.  You may experience numbness and tingling that travels up the legs or arms.  You may feel burning pain or extremely sharp pain.  The slightest touch may feel extremely sensitive.  You may lose sensation causing numbness.  Movements may be weak, paralyzed, or uncoordinated. 

If peripheral neuropathy progresses to the autonomic nerves that control organs, it can change bowel and bladder functions.  It may also affect breathing, swallowing, digestion, and vision.  It can cause impotence in men. Fainting or dizziness can occur if blood pressure is affected.

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Diagnosis

As peripheral neuropathy is a symptom, your doctor will evaluate you to determine its cause.  Your doctor will review your medical history and examine you.  Blood tests may be used to screen for underlying medical conditions, such as diabetes, thyroid disease, or vitamin deficiencies.

Your examination will include a clinical neurological exam, which includes reflex and sensation testing.  Electromyography (EMG) and nerve conduction studies may be used to assess the speed and strength of nerve signals to certain muscles.  A nerve biopsy may be used to identify abnormalities.  In some cases, imaging scans may be used to help determine if there is pressure on a nerve.

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Treatment

There are many ways to treat and manage peripheral neuropathy.  The treatment that you receive depends on many factors, such as its severity, underlying cause, and the nerves that are involved.  For some people, treatment of the underlying cause results in improvement of symptoms. 

Several types of medications or combinations of medications may be recommended.  Over-the-counter or prescription pain relievers, anti-seizure medications, antidepressants, and local anesthetic patches may be prescribed. 

Physical and occupational therapy may help improve muscle strength, coordination, and range of motion.  Your therapists may recommend braces or splints to position your joints.  Ambulation devices, such as a walker, cane, or crutches can increase mobility.  Your therapists may use transcutaneous electrical nerve stimulation (TENS) to deliver a small electrical current to nerves to relieve pain.  A home evaluation performed by your therapists can ensure that your living space is as safe as possible. 

Lifestyle changes can help peripheral neuropathy.  Examine your feet regularly and report any changes to your doctor.  He can recommend the best types of shoes for you.  Exercise regularly, quit smoking, avoid alcohol, and eat healthy balanced meals.  Your doctor can make specific recommendations for you. 

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Prevention

You may prevent complications from peripheral neuropathy by managing its underlying cause.  Follow your doctor’s advice and attend all of your appointments.  Bring any new changes to your doctor’s attention promptly.

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Am I at Risk

Risk factors for peripheral neuropathy:

• Trauma 
• Pressure from nerve compression 
• Alcoholism 
• Diseases, such as diabetes, cancer, thyroid disease, or kidney failure 
• Infections, such as HIV/AIDS, rheumatoid arthritis, or hepatitis 
• Vitamin B deficiency 
• Chemotherapy 
• Exposure to toxins or poisons

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Complications

Decreased sensation and coordination in the feet or toes increases the risk of falls.  Your therapists can work with you on a fall prevention program. 

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Introduction

Pitcher’s elbow, also called Little League elbow, results from excessive throwing motions used in sports.  It most frequently occurs in baseball, but is associated with other sports that involve throwing.  Pitcher’s elbow causes pain and interferes with motion.  Many cases of pitcher’s elbow respond to rest and nonoperative treatment.  Pitcher’s elbow, if left untreated, can lead to significant problems that require surgery.

Back to Top

Anatomy

The two bones in your forearm, the ulna and radius, and your upper arm bone, the humerus, form your elbow joints.  Muscles, nerves, tendons, and ligaments allow your elbow joints to bend, straighten, and rotate.  Tendons are strong fibers that attach your muscles to your bones, and ligaments connect your bones to each other.

Back to Top

Causes

Pitcher’s elbow occurs in players that participate in sports that require repetitive throwing.  It most frequently affects pitchers, but may also develop in outfielders, catchers, and infielders.  Pitcher’s elbow is associated with other sports as well, including tennis and football. 

Pitcher’s elbow is also known as Little League elbow because it occurs in children and teenagers that play sports.  The condition is especially concerning for this population because their bones are growing and injuries can affect the growth process.  Additionally, their skeletal systems may not be developed enough for the demands of competitive sports.

Pitcher’s elbow results when repetitive throwing puts an excessive strain on the tendons and ligaments in the elbow.  The strong movements can cause the ligaments and tendons to stretch, tear, or pull away from the bone.  If some of the bone is also torn away in the process, it can interfere with normal bone growth and cause deformity.  If the forces are great enough, the bones may slam together, causing the bones or cartilage to fracture, and resulting in a condition called osteochondrosis dissecans.

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Symptoms

Pitcher’s elbow causes pain on the inner side of the elbow.  Your elbow joint may feel like it locks or gets stuck.  It may be difficult to move the elbow as you did before, and it will affect your pitching performance. 

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Diagnosis

Your doctor can diagnose pitcher’s elbow by reviewing your medical history and examining your elbow.  You should tell your doctor about your sports participation, the number of throws you typically perform, and the length of your practice or playing season.  This information will help your doctor determine the magnitude of stress on your elbow.  X-rays or magnetic resonance imaging (MRI) scans will be ordered to view your elbow structures.

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Treatment

You should stop performing throwing activities and allow your elbow to rest if you experience pain.  Ice packs may help relieve pain and swelling.  Following rest, throwing should be returned to gradually.  Therapy can be helpful, and sometimes a review of your pitching motion may be beneficial.  If your pain persists or recurs with throwing activities, you should consult your doctor.

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Surgery

Arthroscopy can both diagnose and treat conditions associated with pitcher’s elbow. Arthroscopic surgery uses an arthroscope and narrow surgical instruments that are inserted through small incisions.  An arthroscope contains a lens and lighting system that allow a surgeon to view inside of a joint.  A miniature camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.  Arthroscopic surgery is associated with shorter recovery times and less pain and bleeding than open procedures.  Following surgery, physical or occupational therapy is helpful for regaining mobility, strength, and function.
 
Arthroscopic surgery is not appropriate in every case, with some problems requiring open procedures.  Your doctor will discuss the type of surgery that is best for your particular problem.

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Recovery

Recovery from pitcher’s elbow is different for everyone.  It depends on the extent of your condition and the type of treatment that you receive.  Most players can return to play when their rehabilitation is complete.  Your doctor will let you know what to expect.

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Prevention

You may prevent pitcher’s elbow by taking breaks from pitching, limiting the amount of throwing that you do, and altering your throwing motion, if necessary.  Be sure to warm-up before pitching.  Exercise to keep your arm strong and flexible. 

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Introduction

Plantar fasciitis is a painful foot condition.  It occurs when connective tissue at the bottom of the foot, called the plantar fascia, is irritated and inflamed.  The condition commonly occurs among people who spend a lot of time on their feet.  Heel pain that occurs in the morning upon wakening is a hallmark sign of plantar fasciitis.  Fortunately, for the majority of people, symptoms are relieved without surgery.

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Anatomy

The plantar fascia is a thick connective tissue located on the bottom of the foot.  It extends from the heel to the ball of the foot.  The plantar fascia maintains the arch of the foot.

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Causes

Plantar fasciitis is caused by structural problems in the foot.  People with flat feet have an extra long plantar fascia, and people with high arches have a short plantar fascia, which makes them prone to plantar fasciitis.  Sudden weight gain, obesity, and prolonged standing or walking on hard surfaces contributes to the condition.  

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Symptoms

Plantar fasciitis can cause significant heel pain.  The pain is usually worse in the morning upon awakening, following rest, or after being on your feet for long periods of time.  The pain may subside after walking or stretching, which helps relax the plantar fascia. 

Many people with plantar fasciitis develop heel spurs.  Heel spurs are abnormal bony growths that form under the heel.  They occur as a result of ongoing plantar fascia inflammation or if the plantar fascia pulls away from the bone.

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Diagnosis

Your doctor will review your medical history and examine your foot.  You should tell your doctor about your symptoms and the amount of time that you spend on your feet.  X-rays, bone scans, or magnetic resonance imaging (MRI) scans may be used to give more information about your foot structure and identify the location and size of a heel spur.

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Treatment

In the majority of cases, plantar fasciitis is treated non-surgically.  Rest, ice, and over-the-counter anti-inflammatory or prescription medications can help ease symptoms.  Cortisone injections may also be used.  It can be helpful to lose weight and not go barefoot.

You may be referred to a physical therapist to learn exercises to stretch and help relax the tissues in the heel.  Your doctor may recommend custom orthotics, shoe inserts, or a removable walking cast to help position your foot and cushion your heel.  Night splints can help while you sleep.

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Surgery

Surgery is necessary a very small percentage of the time.  It may be considered after non-surgical treatments have failed.  Plantar fascia release surgery is used to relax the plantar fascia.  This surgery is commonly paired with tarsal tunnel release surgery.  Surgery is successful for the majority of people.

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Recovery

The majority of people with plantar fasciitis improve after a few months of non-surgical treatment.  It is important to follow your doctor’s instructions.  Let your doctor know if your symptoms do not improve after a few months so that your treatment plan can be reassessed.

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Prevention

Customized orthotics and insoles can help relieve foot pressure.  It is important to perform your exercises to help keep your foot stretched and relaxed.  Maintaining a healthy weight can help as well.

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Introduction

Platelet-Rich Plasma (PRP) Therapy is a cutting-edge procedure that is revolutionizing the field of orthopedic medicine.  PRP therapy is a new treatment that relieves pain and promotes long lasting healing of musculoskeletal conditions. PRP Therapy uses components of the body’s own blood cells to formulate a customized “cocktail” that stimulates the natural healing process in certain orthopedic conditions. 

The body’s first response to any soft tissue injury is to deliver platelet cells. Filled with healing and growth factors, platelets jump start the repair process and attract the essential aid of stem cells. PRP therapy’s natural healing process magnifies the body’s efforts by delivering a higher concentration of platelets through a simple injection.

PRP therapy is associated with reduction in pain and faster healing, and has lower risks and lower costs than surgery.

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Causes

Platelet rich plasma (PRP) therapy is a rapidly emerging technique that is showing exciting potential, particularly with soft tissue injuries such as to tendons and ligaments.

A main benefit of PRP Therapy is that it provides pain relief and healing and can eliminate the need for surgery and prolonged recovery.  It may also be used as a treatment for some people that are not candidates for surgery. PRP Therapy is a low-risk minimally invasive procedure. It uses the body’s own cells and natural biological healing process. The concentrated platelet rich plasma (PRP) that is injected into and around the point of injury jump-starts and significantly strengthens the body’s natural healing process.  Recovery with PRP therapy is often much faster than with surgery. Because your own blood is used, there is no risk of a transmitting infection and a very low risk of allergic reaction.

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Treatment

PRP Injections are a much simpler procedure than surgery. PRP Injections are short office procedures. To complete PRP therapy, a sample of your blood is drawn (similar to a lab test sample) and the blood is then spun at high speeds, separating the platelets from the other components. The concentrated platelet rich plasma (PRP) is then injected into and around the point of injury. No stitches are necessary since just a needle was used.

The procedure takes under an hour, including preparation and recovery time. Performed safely in the office, PRP therapy relieves pain without the risks of surgery, general anesthesia, or hospital stays and without a prolonged recovery. In fact, most people return to their jobs or usual activities right after the procedure.

Up to three injections may be given within a 3-month time frame, usually performed two to three weeks apart. You may, however, gain considerable to complete relief after the first or second injection.

The goal of PRP therapy is to resolve pain through healing. Initial improvement may be seen within a few weeks, gradually increasing as the healing progresses. Studies have shown PRP therapy to be effective at relieving pain and returning patients to their normal activities and daily lives. Both ultrasound and MRI images have shown definitive tissue repair after PRP therapy, confirming the healing process. The need for surgery can also be greatly reduced by treating injured tissues before the damage progresses and the condition is irreversible.

Recent News

Recent news headlines have featured the amazing results that professional athletes have experienced with PRP Therapy. Pro football players Hines Ward and Troy Polamalu of the Pittsburgh Steelers received PRP Therapy after injuries that should have side-lined them for months, but they returned to play in a matter of weeks, winning the Super Bowl.  Los Angeles Dodgers pitcher Takashi Saito received PRP Therapy for an elbow condition and returned to play in just a few months, versus up to 14 months that recovery from surgery would have taken. Unprecedented results have also been reported for other professional soccer, baseball, and football players. While PRP Therapy is just beginning to become mainstream news, it actually has been around for quite some time.

Although PRP Therapy is relatively new to the field of orthopedics, it has been used for more than 20 years in dentistry.  PRP Therapy has been used to promote healing following jaw reconstruction for patients with cancer.  Its use has expanded to other medical specialties, including cardiovascular surgery, sports medicine, urology, cosmetic surgery, and ophthalmology. These studies show that recovery time is quicker and the risks are lower with PRP Therapy.  Researchers are now focused on its use in musculoskeletal injuries.

In the field of orthopedics, PRP Therapy is being studied for use in the joints, spine, bone, ligaments and tendons.  Because the studies have used a small number of participants, larger studies are necessary before the results can be generalized.  Researchers are optimistic that after future studies, insurance will cover the procedure, and speculate that the procedure may become a protocol before surgical treatment.

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Introduction

The posterior cruciate ligament (PCL) crosses inside of the knee joint with the anterior cruciate ligament (ACL), connecting the thighbone to the leg.  Ligaments are strong non-elastic fibers that connect your bones together.  PCL tears are not as common as ACL tears, but can result from certain twisting movements, falls, or direct contact to the knee or shinbone during contact sports.   Some PCL tears are treated with nonsurgical methods.  However, if other knee structures are injured as well, arthroscopic surgery is used to restore knee strength, stability, and motion.

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Anatomy

The knee is structurally complex.  It is composed of three bones.  The thighbone (femur), sits on the larger leg bone (tibia).  The kneecap (patella) glides in a groove on the end of the femur.

Large muscle groups in the thigh give the knee joint strength and stability.  The quadriceps muscles are a large group of muscles on the front of the thigh that straighten and rotate the leg.  The hamstring muscles are located at the back of the thigh.  The hamstring muscles bend or flex the knee.

Four ligaments connect the knee bones together.  Ligaments are strong tissues that provide stability and allow motion.  The ligaments enable the knee to have the flexibility to move in various directions while maintaining stability. . 

The anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) cross inside of the knee joint.  The ACL and PCL help to keep the joint aligned.  The ACL and PCL counteract excessive forward and backward forces and prohibit displacement of the bones.  The ACL and PCL control rotation of the tibia.  You rotate your tibia when you turn your leg outward to push off the ground with the foot. For example, you use this motion to push off from the side to skate, run, or move your body to get into a car seat.

The medial collateral ligament is located on the inner side of the knee.  The lateral collateral ligament is at the outer side of the knee.  The medial collateral ligament and the lateral collateral ligament help the knee joint resist side to side stress and maintain position.

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Causes

PCL injuries take place if the shinbone is impacted by force just below the knee or on the side of the knee while the leg is twisted,  bending the knee more than its normal range, or from falling on a flexed knee with the toe pointed.  PCL injuries can occur during contact sports, such as football or soccer.  They can also result from car crashes.

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Symptoms

Because initial symptoms can be vague, some people may not know that they have a posterior cruciate ligament injury until the pain worsens over time and the knee feels unstable.  PCL tears can cause:

• Knee pain ranging from mild to moderate
• Rapid knee swelling and; tenderness
• Pain while kneeling, squatting, running, slowing down, or walking stairs or ramps
• Limping or problems walking
• Knee instability, a feeling that the knee is "giving out"

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Diagnosis

If you suspect that you have a posterior cruciate ligament tear, you should go to your doctor or an emergency department.  A doctor can evaluate your knee for a PCL injury by reviewing your history, examining your knee, and reviewing medical images.  Your doctor will ask about your symptoms and the circumstances of your injury. 

Your doctor will order X-Rays to see the condition of the bones in your knee and to identify fractures.  It is not uncommon for bone or cartilage to be injured with the ligaments in a knee injury.  Commonly magnetic imaging (MRI) scans are used to best see the ligament injury, and associated injuries.

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Treatment

Initially following a posterior cruciate ligament injury, you should treat your knee with rest, ice, gentle compression, and elevation (R.I.C.E. Method).  You should rest your knee by not placing weight on it.  You may use crutches to help you walk.  Applying ice to your knee can help reduce pain and swelling.  Apply ice to your knee immediately following injury and then comply with your doctor's icing schedule.  Elevating your knee at a level above your heart can help reduce swelling.

Your doctor may recommend over-the-counter or prescription pain medication.  In some cases, people with a PCL tear wear a knee brace to support the knee. 

Physical therapy rehabilitation begins as the swelling diminishes.  A physical therapist will show you specific exercises to strengthen the quadriceps muscles and other muscles that support the knee joint.  The goal of physical therapy is to strengthen the knee and restore function.

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Surgery

Surgery is almost always necessary for people with posterior cruciate ligament occurring with other types of knee injuries, such as cartilage or other ligament tears.  Your orthopedic surgeon may recommend that you participate in physical therapy prior to surgery to ensure that the muscles surrounding your knee are strong.  PCL surgery is usually an outpatient procedure.  The goal of PCL repair surgery is to restore the function of the PCL to maintain the knees mobility, stability, and function, while preventing further injury. 

During PCL surgery, the damaged PCL is removed and replaced with a healthy ligament, a graft.  There are a few options for acquiring grafts.  Grafts may be taken from another part of the body or from a donor cadaver.  An orthopedic surgeon uses an arthroscope to perform surgery on a PCL tear. 

An arthroscope is a very thin surgical instrument, about the size of a pencil.  It contains a lens and lighting system that allows a surgeon to see inside a joint.  The surgeon only needs to make small incisions and the joint does not have to be opened up fully.  The arthroscope is attached to a miniature camera.  The camera allows the orthopedic surgeon to view the magnified images on a video screen. Arthroscopic PCL repair is associated with less pain, reduced risk of infection, decreased swelling, and faster recovery times than open PCL surgery.

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Recovery

Surgically placed grafts may take several months to heal to the knee bones.  Physical therapy rehabilitation follows PCL surgery to help decrease swelling, increase mobility and stability, and increase strength and knee function.

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Introduction

Posterior tibial tendon dysfunction, also known as acquired flatfoot, results when the tendon at the back of the ankle is inflamed or torn.  It is a progressive condition that can eventually lead to a fallen arch or flatfoot.  Advanced cases, or those that do not respond to non-surgical treatments, may require surgery.  There are various surgical procedures for posterior tibial tendon dysfunction, and it is common to need more than one.

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Anatomy

The posterior tibial tendon connects at the calf, travels around the inside of the ankle joint, and attaches to the bones in the midfoot.  It maintains the arch in your foot and provides stability when you walk.

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Causes

Posterior tibial tendon dysfunction results when the tendon becomes inflamed or torn.  Sports injury and overuse can contribute to posterior tibial tendon dysfunction.  Certain medical conditions, such as obesity, hypertension, diabetes, and arthritis increase the risk of the condition.  Problems with this tendon are more common in women.

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Symptoms

Posterior tibial tendon dysfunction most frequently develops in one foot, but it can affect both feet.  Symptoms are usually progressive, meaning they get worse over time.  You may first notice pain, redness, and swelling along the inside of your ankle and foot.  As the arch in your foot flattens, you may experience pain in your outer and midfoot, weakness, and the inability to stand on your toes.

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Diagnosis

You should see your doctor if you suspect that you have posterior tibial tendon dysfunction.  Early diagnosis and treatment can help stop the progression of the condition.  Your doctor can diagnose posterior tibial tendon dysfunction by reviewing your medical history, examining you, and conducting some tests. 

Your doctor will ask you to stand or move your foot in certain ways so that it can determined how your tendon is functioning.  X-rays, ultrasound, or magnetic imaging resonance (MRI) imaging may be used to provide pictures of your ankle and leg structures.

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Treatment

In some cases, early non-surgical treatment can help prevent the need for surgical treatment in the future.  In the early stages, pain and swelling are treated with rest and aspirin or ibuprofen.  A short leg cast or boot may be worn while the tendon heals.  Physical therapy usually follows casting to help the ankle joint gain range of motion and strength.  You may be issued an ankle stirrup, custom orthotic device, or custom shoe insert to help support your foot.

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Surgery

Surgery may be recommended when non-surgical treatments fail to provide symptom relief, or for advanced cases of posterior tibial tendon dysfunction.  There are several types of surgery, and you may need more than one type of procedure.  Surgery is used to removed inflamed tissue, improve the position of the heel bone, transfer another tendon for reconstruction, or fuse bones together to prevent movement and add stability. 

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Recovery

Following surgery, you may need to wear a protective splint, cast, or boot.  Physical rehabilitation exercises can help you regain strength and stability.  You may need to use a cane or crutches at first. 

Recovery is individualized.  The amount of time you need to heal depends on the extent of your condition and the procedures that you received.  Your doctor will let you know what to expect.

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Prevention

In some cases, early diagnosis and treatment can stop the progression of posterior tibial tendon dysfunction.  You should wear the arch supports, custom orthotic inserts, or orthotic shoes  recommended by your doctor.

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Introduction

Radial tunnel syndrome occurs when the radial nerve in the arm is compressed.  The radial nerve travels through the radial tunnel located on the top (dorsum) of the forearm.  The radial nerve can be compressed or irritated in the radial tunnel due to repetitive movements, forceful forearm movements, or injury.  Radial tunnel syndrome causes hand weakness and pain in the forearm near the elbow.  Most cases are treated with rest, rehabilitation, and splinting.  Surgery is recommended when all other treatments have failed.

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Anatomy

Your radial nerve originates from nerve roots in the neck which then combine about the base of the neck and shoulder, and travels down your arm.  The radial tunnel is made of muscles and bones.  From the radial tunnel, the radial nerve runs underneath the supinator muscle.  It then branches out into your forearm and hand.  Near the supinator, the radial nerve branches into a sensory nerve and the motor branch called the posterior interosseous nerve. The radial nerve controls movements in the muscles on the back of your arm and forearm, which are mainly extensors.  The posterior interosseous nerve controls extension movements in your wrist, fingers, and thumb.

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Causes

Radial tunnel syndrome occurs when the radial nerve is compressed.  This can happen if the radial tunnel is too small.  Repetitive movements, such as twisting movements of the forearm, forceful wrist movements, gripping, and pinching can irritate, stretch, or compress the nerve.  This type of injury can occur on the job, for instance in construction or manufacturing work.  A direct blow to the forearm or elbow can also injure the radial nerve.

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Symptoms

Radial tunnel syndrome causes an aching pain in the forearm.  The pain is centered a few inches below your elbow joint where the radial nerve travels beneath the supinator.  The pain may become worse when you extend your wrist, turn your palm upward (supinate), or hold something while your arm is straight out.  Your forearm, wrist, and hand may feel weak.  You may have difficulty extending your wrist, which is termed wrist drop.

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Diagnosis

Your doctor can diagnose radial tunnel syndrome by reviewing your medical history and examining your arm.  You should tell your doctor about your activities, injuries, and symptoms.  X-rays will be performed to check for abnormalities that may be affecting the nerve.  Pinpointing the location of the pain source is necessary to distinguish radial tunnel syndrome from other conditions, such as tennis elbow.

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Treatment

The most important way you can relieve your symptoms is to avoid the repetitive movements that caused the problem.  If repetitive movements are part of your job, you should take frequent breaks and modify your work duties.  An occupational therapist can evaluate your workstation and may be able to help you prevent injuries. 

Your doctor can refer you to a hand therapist or occupational therapist for splinting and rehabilitation.  A splint will position your arm to allow the radial nerve to heal.  At rehabilitation, you will learn proper ways to do your activities to reduce irritating the radial nerve.  Your therapist will use modalities, such as icing and heat to ease your pain.  You will also learn exercises to keep your forearm and hand muscles healthy

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Surgery

Surgery for radial tunnel syndrome is used only when all other treatment options have failed.  The goal of surgery is to relieve the pressure on the radial nerve to eliminate your symptoms.  Radial nerve surgery is usually an outpatient procedure. 

There are generally two approaches to the radial nerve.  There is a muscle splitting approach, which limits exposure to the region of the supinator muscle, or an extended approach that addresses all possible sites of radial nerve compression in the forearm.  Your surgeon will decide which approach is most appropriate for your case.  Tissues that are compressing your radial nerve are incised, easing pressure on the nerve.  At the end of the procedure, your skin is stitched and bandaged.  You will wear a splint on your arm and participate in rehabilitation therapy for several weeks.

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Recovery

Recovery from radial tunnel syndrome is different for everyone.  Your recovery will depend on the extent of your condition, the type of treatment you received, and your compliance with therapy and splinting.  Recovery following surgical treatment can take months.  You should experience improvements in about four to six weeks with nonsurgical treatments.  Your doctor will let you know what to expect

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Prevention

You may prevent radial tunnel syndrome by avoiding repetitive movements including twisting the forearm, extending the wrist, and gripping.  It is important to take frequent breaks if you must perform these motions.  It is helpful to have an occupational therapist examine your work site to make modifications to possibly prevent injuries.

If you experience radial tunnel syndrome, you may enhance your recovery by complying with your splint wearing schedule and attending all of your rehabilitation therapy appointments.  Practice your home therapy exercise program.  Integrate activity modifications to protect your radial nerve.

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Introduction

Reverse shoulder replacement is an advanced newer surgical treatment that was approved by the FDA in 2004. A reverse shoulder replacement is a surgical procedure to replace a damaged shoulder joint with an artificial one. The new joint stabilizes the joint to allow pain-free movement and function.

A reverse shoulder replacement is used for people with certain complex shoulder conditions. In contrast to total shoulder replacement surgery (shoulder arthroplasty), the components of the artificial joint are placed in reversed positions to allow the deltoid muscle at the shoulder to raise the arm. Like traditional total shoulder replacement, physical therapy following the procedure helps to ensure the best outcomes.

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Anatomy

The shoulder joint has a greater range of motion than any other part of the body.  Because the shoulder joint can perform so many movements, it’s structure of bones, ligaments, muscles, blood vessels, and nerves is more complex than other joints in the body.  The shoulder joint’s structure and great range of motion make it vulnerable to injury.

The shoulder joint has three bones.  The humerus is the bone in the upper arm.  The clavicle bone is commonly referred to as the collarbone.  The acromion is the bone at the top of the shoulder.  The acromion is actually part of a larger bone, called the scapula (shoulder blade), which is located on top of the ribs on the upper back.

There are a total of four joints in the shoulder complex.  The humerus and scapula form the main shoulder joint, the glenohumeral joint.  The glenohumeral joint is not a true ball-in-socket joint like the hip, but it is similar in structure.  The head of the humerus is round like a ball.  During movement, the head of the humerus rotates in a shallow basin, called the glenoid, on the scapula.  A group of ligaments,  together called the joint capsule, hold the head of the humerus in position.  Ligaments are strong tissues that provide stability.  The ligaments in the joint capsule are responsible for holding the arm in place on the body.

Several ligaments connect the shoulder bones together.  The tendons in the shoulder attach muscles to the bone.  Your muscles move your bones by pulling on the tendons. The rotator cuff tendons connect strong muscles to the humerus bone.  These muscles allow the arm to rotate and move upward to the front, back, and side, as well as overhead.  A structure, called the subacromial bursa, lubricates the rotator cuff tendons and allows you to perform smooth and painless motions.

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Causes

The purpose of a reverse shoulder replacement is to stabilize the shoulder joint and restore pain-free motion and function. People with multiple shoulder conditions, such as arthritis with a rotator cuff tear or vascular damage (avascular necrosis/osteonecrosis), may be candidates for reverse shoulder replacement. With significant degenerative shoulder conditions, the protective cartilage may wear away on the bones causing painful and limited movement or the rotator cuff tendons are so damaged that they contribute to pain and do not function properly. A reverse shoulder replacement may also be used for people that experienced an unsuccessful traditional shoulder replacement.

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Symptoms

Degenerative shoulder conditions can eventually destroy the structures in the shoulder joint. When the shoulder does not work at it should, pain and loss of motion can develop. In fact, reverse shoulder replacement can be a treatment option for people with very little or no shoulder motion, depending on the cause. Such factors can limit the use of the shoulder for functional tasks or recreational activities.

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Diagnosis

Your doctor can diagnose degenerative changes in the shoulder by conducting a physical examination.  You should tell you doctor about your symptoms and level of pain.  The examination will include performing simple arm and shoulder movements to help your doctor assess your muscle strength, joint motion, and joint stability.

X-rays help determine the condition of your shoulder bones and show abnormal bone growths (bone spurs), as well as loss of joint cartilage.  Advanced imaging tests, such as a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan, may be ordered for a more detailed view.

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Surgery

A reverse shoulder replacement is recommended for people with a completely torn rotator cuff that cannot be repaired, severe arthritis with rotator cuff damage, or prior failed shoulder surgery. Traditional total shoulder replacement surgery would still leave these individuals with inability to lift their arm.

With a reverse shoulder replacement surgery, the position of the ball and socket in the joint are switched. The metal ball is attached to the scapula, and the artificial socket is attached to the end of the humerus. Such placement allows the deltoid muscle, instead of the damaged rotator cuff muscles, to lift the arm above the shoulder.

A reverse shoulder replacement is an inpatient procedure. To begin, your surgeon will make an incision on the front of your shoulder. Your surgeon will remove the damaged head of the humerus. The bone socket is exposed, and the damaged cartilage is removed. A base plate is secured to the glenoid with surgical screws. The artificial socket is inserted and secured on the humerus. The ball is inserted and secured on the glenoid. The wound is closed, and a soft dressing is applied.

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Recovery

You will remain in the hospital for one or two days following your procedure. Some surgeons restrict shoulder movements for about three weeks. You will wear an arm sling for support.

Participating in physical therapy will help you gain motion, strength, joint stability, and coordination. At first, your therapist will help you gently move your arm. You will gradually work towards moving your arm independently. You will learn exercises to strengthen and increase the movement in your shoulder. You should be able to lift your arm above your shoulder. Eventually, your therapists will provide you with a home exercise program.

Recovery from reverse shoulder replacement surgery is individualized. It usually takes many weeks to recover from the surgery completely. Your doctor will tell you what to expect.

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Introduction

Rheumatoid arthritis commonly affects the hand.  Rheumatoid arthritis is a long-term chronic inflammatory disease.  It causes the joints in the hand to become painful, swollen, and stiff.  Rheumatoid arthritis can lead to hand deformity and loss of function.  Symptoms are treated with medications, hand therapy, splinting, and surgery.

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Anatomy

Your fingers are made up of three bones called phalanges.  Two joints separate the phalanges.  The distal interphalangeal (DIP) joints are located near your fingertips.  The proximal interphalangeal (PIP) joints are located in the middle of your fingers.  The hand above your fingers is made up of five metacarpal bones.  Your metacarpophalangeal (MP) joints are located at the base of your fingers and thumb.  The MP joints allow your fingers and thumbs to move up and down and from side to side.

The bones in your finger joints are covered with cartilage.  Cartilage is a very tough shock absorbing material.  The cartilage forms a smooth surface and allows the bones in your joints to glide easily during motion.  A membrane called a synovium covers the joint.  The synovium secretes a fluid called synovial fluid.  The synovial fluid acts as a cushion and lubricant between the joints.  It reduces friction between the bones and helps prevent “wear and tear.”

Ligaments are strong tissues that connect your hand bones together and provide stability.  Your ligaments are also lined with synovium.  The synovial fluid allows the ligaments to glide by the joints easily during movement.  Tendons are strong fibers that attach your muscles to your bones.  The tendons and muscles power your hand joints and enable them to move.

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Causes

Rheumatoid arthritis is a common form of arthritis that frequently affects the hand.  Rheumatoid arthritis causes the synovium to become inflamed and swollen.  It causes the cartilage and bones to deteriorate.  Tissues surrounding the joint may also be affected.  As swelling occurs, the tendons and ligaments stretch.  This can lead to joint malalignment and deformity.  Rheumatoid arthritis is one of the most serious and disabling types of arthritis.

The primary cause of rheumatoid arthritis is unknown.  Arthritis can occur for many reasons, including aging, “wear and tear,” autoimmune disease, and inflammatory disease.  Rheumatoid arthritis can occur in the small and large joints of the body.  Many joints may be involved at the same time.  Rheumatoid arthritis tends to occur symmetrically, meaning that if one hand develops it, the other hand does too.  Rheumatoid arthritis can affect people of all ages, but it most frequently occurs in women and those over the age of 30.

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Symptoms

Rheumatoid arthritis most frequently affects the MP joints in the hand.  Your joints may feel stiff, swollen, and painful.  You may have difficulty moving your fingers.  You may hear creaking noises when you move your joints.  This is a sign that the cartilage is affected.  It may be difficult to use your hands for your regular activities.  Your symptoms may increase after you have used your hands.

Your joints may be unstable and unable to achieve their normal positions and motions.  Your fingers may move from their normal positions and lean towards your little finger.  This is called an ulnar drift.  Your DIP and PIP joints may bend in the opposite way they are supposed to creating a crooked finger.  This can result in a boutonniere deformity or a swan neck deformity.

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Diagnosis

Your doctor can diagnose rheumatoid involvement of the hand by reviewing your medical history and examining your hand.  You will be asked about your symptoms and level of pain.  You may be asked to perform simple movements to help your doctor assess your muscle strength, joint motion, and joint stability.  Blood tests and other laboratory tests can help identify rheumatoid arthritis.  Your doctor will order x-rays and perhaps other imaging tests to provide more information about your joints.

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Treatment

There is no cure for rheumatoid arthritis.  It is a life long condition.  You may experience times when symptoms flare up and times when symptoms are not so bad.  Treatments for rheumatoid arthritis of the hand are aimed at reducing pain, improving mobility, increasing function, and preventing further injury.  Treatment options include medications, splinting, hand therapy, and surgery.  The type of treatment that you receive depends on the severity and extent of the arthritis in your hands.  Your activity level and desired outcomes are considered as well.

Over-the-counter or prescription medications may be used to reduce swelling and pain.  In some cases, injected medications may be used.  Injections are usually combined with joint splinting.  Splints are worn during activities to provide support to the joints.

Hand therapy can help reduce pain, swelling, and restore movement.  A hand therapist may use modalities, such as warm wax soaks (paraffin bath) or warm water soaks to help ease your pain and improve joint flexibility.  Your hand therapist can recommend products you can use at home to make some tasks easier.  A hand therapist can also recommend ways to adapt your hand movements during ordinary tasks to protect your joints.

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Surgery

If non-surgical treatments fail, there are many surgical options for rheumatoid arthritis of the hand.  The goals of surgical treatments are long-term pain relief and improved functioning.  Reconstructive surgery can restore damaged joints.  A joint can be removed and replaced with an artificial joint.  An artificial joint can restore pain-free motion. 

Joint fusion is another surgical option.  Joint fusion surgery secures the bones in a joint together.  Joint fusion can relieve pain, but it does not restore movement because the joint cannot move.  All joint surgeries are usually followed by hand therapy.
 
There are many other surgical procedures for rheumatoid arthritis of the wrist and hand.  Depending on your particular problems, other procedures include removing inflamed synovium from a joint (synovectomy), rebalancing tendons that have moved out of place, removing bone spurs that rub on tendons, and repairing ruptured tendons.

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Recovery

Recovery times vary from individual to individual.  Generally, most people can return to their regular activities at about three months following their surgery.  Your doctor will let you know what to expect.

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Prevention

There is no known way to prevent or cure rheumatoid arthritis of the hand.  Symptoms tend to appear gradually over time.  You may be able to relieve your symptoms and prevent deformities by adapting the way that you use your hand for activities.  A hand therapist or an occupational therapist can advise you on joint protection methods.  The therapists can recommend adaptive equipment, such as grooming tools or kitchen utensils with built up handles, to relieve stress on your joints.  It is important to wear your splints as directed and participate in your home exercise programs.

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Introduction

Rotator cuff tears are a common source of shoulder pain. The rotator cuff consists of four shoulder muscles and their tendons. Tendons are strong fibers that connect our muscles to our bones. The shoulder muscles and tendons cover the upper end of our arm bone forming a cuff. 

The risk of rotator cuff tears increases with age. The aging process can cause the tendons and muscles to degenerate and weaken. Rotator cuff tears can also result from sudden shoulder movements or overuse, for instance during sports, such as pitching in baseball or playing tennis, or falls. 

The decision on how to treat rotator cuff tears is very individualized. Some rotator cuff tears can be treated with non-surgical methods. However, surgical procedures have become less invasive, resulting in good outcomes with improved recovery times.

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Anatomy

Our shoulder is composed of three bones. The humerus is our upper arm bone. The clavicle is what we call our collarbone. The scapula is the shoulder blade that moves on our back. An edge of the scapula, called the acromion, forms the top of the shoulder. There are a total of four joints in our shoulder complex. The humerus and the scapula form the main shoulder joint, the glenohumeral joint. 

The glenohumeral joint is not a true ball-in-socket joint like the hip, but it is similar in structure. The top of the humerus is round like a ball. It rotates in a shallow basin, called the glenoid, on the scapula. A group of ligaments, called the joint capsule, hold the ball of the humerus in position. Ligaments are strong tissues that provide stability. In other words, the joint capsule is responsible for holding our upper arm in place at our shoulder. 

The four rotator cuff muscles form a single cuff of tendon that connects to the head of the humerus bone. The muscles allow the arm to rotate and move upward to the front, back, and side. A fluid-filled sac, called the subacromial bursa, lubricates the rotator cuff tendons allowing us to perform smooth and painless motions. We use the rotator cuff muscles to perform overhead motions, such as lifting up our arms to put on a shirt, comb our hair, or reach for an item on a top grocery shelf. 

These motions are used repeatedly during sports, such as serving in tennis and passing in football. The rotator cuff also provides stability when our elbow flexes and as we lift objects.

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Causes

Rotator cuff tears most frequently occur in the dominant arm but commonly occur in the non-dominant arm. The risk of rotator cuff damage increases with age. With age, the blood supply to our tendons decreases. This causes the tendons and muscles to degenerate, weaken, and become susceptible to tearing. Additionally, the tendon degenerates with age. The body’s ability to repair the tendon decreases over time because of the reduced blood supply. 

Sometimes the aging process can cause bone spurs to grow on the scapula, particularly in the acromion area. Shoulder impingement syndrome occurs when bone spurs or bursa inflammation narrows the space that is available for the rotator cuff tendons. The tendons can tear as they rub across the bone spur, particularly when the arm is elevated. Inflamed tendon membranes may develop tendonitis, a painful condition. Shoulder impingement syndrome may even cause the rotator cuff tendons to detach from the top of the humerus.

Rotator cuff injuries can occur in younger people following a shoulder injury, such as a fracture or dislocation. Overuse or repetitive activity can also cause rotator cuff tears. This includes athletes that perform overhead movements during such sports as tennis, swimming, or baseball. This also includes workers who reach upwards repetitively during construction, painting, or stocking shelves.

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Symptoms

The symptoms of a rotator cuff tear tend to appear gradually. You may first develop pain in the front part of your shoulder. Your pain may spread down the side of your arm. The pain may be mild at first and increase when you lift your arm or lower your arm from a fully raised position. Over time, the pain may be present when you rest and even wake you while you sleep. However, some rotator cuff tears are not painful at all. 

Your shoulder may feel stiff. It may be difficult for you to move your arm. You may hear a crackling noise when you do so. Your arm may feel weak, especially when your lift or rotate it. 

The symptoms of a rotator cuff tear caused by traumatic injury occur suddenly. You may feel a snap and sudden pain. Your arm will immediately feel weak, and you will have difficulty moving it.

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Diagnosis

A doctor can evaluate your shoulder by performing a physical examination and viewing medical images. Your doctor will ask you about your symptoms and medical history. You will be asked to perform simple movements to help your doctor assess your muscle strength, joint motion, and shoulder stability. 

Your physician will order X-rays to see the condition of the bones in your shoulder and to identify arthritis or bone spurs. A special dye may be used with the X-ray in a procedure called an Arthrogram. Sometimes a soft tissue injury does not show up on an X-ray. In this case, your doctor may order a Magnetic Resonance Imaging (MRI) scan or an ultrasound. A MRI scan will provide a very detailed view of your shoulder structure. It will help your doctor determine the location and type of your rotator cuff tear. An ultrasound uses sound waves to create an image when a device is gently placed on your skin. These tests do not hurt but require that you remain very still while a camera takes images.

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Treatment

Many rotator cuff tears can be treated with non-surgical methods including rest and pain relief. Limiting overhead arm movements and wearing a sling may help to reduce symptoms. Over-the-counter medication or prescription medication may be used to reduce pain and swelling. If your symptoms do not improve significantly with these medications, your doctor may inject your joint with corticosteroid medication. Corticosteroid medication is a relatively safe pain reliever. Physical and occupational therapy can be helpful to restore strength and function.

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Surgery

Surgery is recommended when non-operative treatments have provided minimal or no improvement of your symptoms. Surgery may also be recommended for painful injuries or for people who rely on their arm strength for work or sports. There are several types of surgeries that can be performed for rotator cuff tears. The type of surgery that you have depends on the size, shape, and location of your tear. 

Partial rotator cuff tears may only require debridement. This surgical procedure simply trims the tendon. Suturing the tendon together repairs a complete tear. Additionally, tendons can be reattached to the bone. Many of these surgeries can be done as outpatient procedures. You will be anesthetized for the surgery. Three common surgical approaches include Open Surgical Repair, Mini-Open Repair, and Arthroscopic Repair.

Open Surgical Repair is the original type of surgery for rotator cuff tears. During Open Surgical Repair, the surgeon opens the shoulder complex to gain access to the torn rotator cuff. Your surgeon will make an incision over your shoulder and detach a small portion of the deltoid muscle for the surgery. An Acromioplasty is often performed at the same time. An acromioplasty removes bone spurs from underneath the acromion. 
A Mini-Open Repair of the rotator cuff is a variation of the Open Surgical Repair. The Mini-Open Repair uses much smaller incisions, typically three to five cm. in length. The deltoid muscle is not detached in this procedure. Instead, the surgeon views and evaluates the joint using an arthroscope. 

An arthroscope is a very small surgical instrument. It is about the size of a pencil. An arthroscope contains a lens and lighting system that allows a surgeon to view inside of a joint. The arthroscope can be attached to a miniature camera. The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape. With this technology, your surgeon will only need to make small incisions and will not need to open up your joint fully.

The arthroscope is used to remove bone spurs under the acromion and to treat other structures in the shoulder joint. Your surgeon will then use a mini-open incision to repair the rotator cuff. Results of the Mini-Open Repair are equal to the Open Repair surgical method.

Another option for rotator cuff repair is All-Arthroscopic Repair. This technique is commonly used to reconstruct ligaments or remove damaged tissue and bone spurs. Arthroscopy is less invasive than traditional surgical methods. It has a decreased risk of infection and a shorter recovery period.

Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your shoulder joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert the arthroscope and may reposition it to see your joint from different angles. 

Your surgeon may make additional small incisions and use other slender surgical instruments for surgical treatments. Because the surgical incisions are so small, they will require just a few stitches or Steri-Strips. Your surgeon will cover them with a bandage.

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Recovery

Your shoulder will need several weeks to heal from the surgery. Your surgeon will restrict your arm movements for a short period of time following your procedure. You will most likely wear an arm sling for four to six weeks. An occupational or physical therapist will gently help you move your arm at first, and then you will progress to strengthening exercises. 

Generally, most individuals regain functional movement and strength by four to six months after surgery. Your recovery time will depend on the extent of your condition and the amount of surgery that you had. Your surgeon will let you know what to expect. 

Overall, arthroscopic shoulder surgery requires a shorter length of time for recovery than open joint surgery. It also has a reduced risk of infection, less blood loss, and less pain and stiffness because only small incisions are used and less surrounding tissue is affected or exposed. Most individuals achieve good results with rotator cuff repair. All methods of surgery appear to produce equal results.

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Prevention

It may be helpful to exercise to maintain a strong, stable, and flexible shoulder. Avoiding repetitive overhead movements may help to prevent rotator cuff tears. Further, it is important to follow your doctor’s instructions for any weight lifting or motion restrictions.

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Introduction

A scaphoid fracture most commonly results from a fall on an outstretched hand.  The scaphoid is a small bone located on the thumb side of your wrist.  It is the most commonly broken bone in the wrist.  Because symptoms can be minimal, scaphoid fractures are frequently mistaken as sprained wrists.  Scaphoid fractures require casting or surgery.

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Anatomy

The scaphoid is a small bone located on the thumb side of your wrist.  The scaphoid is unique in that it spans the two rows of bones that make up your wrist.  Because of its position, it is the most commonly broken bone in the wrist.

Unfortunately, the blood supply to the scaphoid is somewhat unusual, and this can lead to problems in fracture healing.

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Causes

A scaphoid fracture most frequently results from a fall on an outstretched hand.  Motor vehicle crashes and sports injuries can also cause scaphoid fractures.  The outcome of scaphoid fractures is largely dependent on the location of the break in the bone and the amount the bone fragments have displaced or shifted.  Fractures near the end of the bone toward the hand have the greatest blood supply and heal the best. Fractures located in the middle of the scaphoid (the waist) or closer to the forearm (the proximal pole) sometimes have trouble healing because the blood supply to these areas is poor.

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Symptoms

A scaphoid fracture causes tenderness directly over the bone.  This is an area known as "the anatomic snuffbox."  Your pain may increase when you move your thumb or grip things.  Your initial pain may decrease over days or weeks.  Scaphoid fractures usually do not cause bruising or significant swelling, which is the reason they are often mistaken for a sprained wrist.

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Diagnosis

Your doctor can diagnose a scaphoid fracture by examining your wrist and taking X-rays.  Sometimes scaphoid fractures do not show up on initial X-rays.  The X-rays may be repeated later, or computed tomography (CT) scans or magnetic resonance imaging (MRI) scans may be used because they show more detail.  CT scans are frequently performed, as the degree of fracture displacement is often difficult to determine from plain X-rays.

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Treatment

Treatment depends on the location, fracture type, and fracture location in the bone.  Fractures located near the thumb (distal pole) heal well with casting.  Fractures in areas with a poor blood supply and displaced fractures generally require surgery.

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Surgery

Surgery for scaphoid fractures can be done through a tiny incision when the bone fragments do not need to be reduced (manipulated).  Otherwise, a relatively small incision at the base of the thumb is needed.  The surgical approach is determined by the fracture location in the bone.  Headless screws, of which there are several types, are used to hold the scaphoid bone in position while it heals.  A cast or splint is worn for some time following surgery.

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Recovery

It can take a scaphoid fracture a few months to heal.  You will participate in hand therapy rehabilitation when your cast is removed.  You should avoid gripping and heavy lifting, as well as contact sports, until cleared to do so by your doctor.  

Some scaphoid fractures have a difficult time healing.  There can be delayed healing, or sometimes the bone will not heal, leading to a nonunion.  In these cases, follow up surgery may be necessary to insert bone grafts.  The bone grafts promote healing because they either bring a blood supply to the area, or growth factors that enhance healing. 

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Prevention

You can prevent scaphoid fractures with fall prevention techniques.  If you participate in sports, you should wear protective equipment such as wrist guards made for skateboarding, inline skating, and snow boarding.

Treating underlying medical conditions can help prevent falls.  A general physical examination can identify medical conditions that cause balance disorders or dizziness.  An early diagnosis may allow for optimal treatment.

It can be helpful to have an occupational therapist, a physical therapist, or a family member help you examine your home and remove obstacles that may cause you to trip.  It can be helpful to install railings on steps or in your shower.  Low-heeled sturdy shoes may help you maintain proper foot positioning.  A cane or walker may aid your balance while you stand or walk. 

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Introduction

The sesamoids are two small bones near the base of the big toe.  They help to bear weight and act as pulleys to help move your big toe when you walk.  Too much repetitive pressure, force, or tension can cause sesamoiditis, an inflammatory condition.  If the impact is great enough, the bones can break (fracture).  The majority of people with sesamoiditis or sesamoid fracture heal well with non-surgical treatment.

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Anatomy

The sesamoids are two very small bones.  They are located at the joint at the base of the big toe on the bottom of the foot.  The sesamoid bones sit in two small grooves and are stabilized by a triangular shaped ligament.  The sesamoid bones help form a pulley system (sesamoid apparatus) for the muscles that move the toe towards the ground when you walk.  They also work with the big toe to bear the forces associated with walking.

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Causes

Sesamoiditis and sesamoid fractures are most frequently caused by significant repetitive pressure and force on the ball of the foot.  Ballet dancers and catchers in baseball are prone to the condition.  However, it may occur from other sources of constant tension and pressure on the forefoot, such as walking, or a strong immediate force, such as falling or jumping from a height.

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Symptoms

Symptoms of sesamoiditis tend to develop gradually and then intensify over time.  You may experience aching increasing to intense pain located beneath your big toe and in the ball of your foot.  Your pain may increase with movement.  It may be difficult to bend or straighten your big toe and to walk. You may or may not experience redness and swelling in the affected area.

A sesamoid fracture causes immediate pain.  You may develop a large bruise under your toe.  Significant swelling throughout the forefoot may make it difficult to bend your toes or walk. 

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Diagnosis

Your podiatrist can diagnose sesamoiditis or a sesamoid fracture by reviewing your medical history and examining your foot.  You should tell your doctor about your activities or any falls or accidents.  X-rays or a bone scan will be taken to help identify a fracture.

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Treatment

Sesamoiditis and sesamoid fractures are most frequently treated without surgery.  Rest, over-the-counter pain medication, and ice can help reduce pain and swelling.  You should wear low-heeled shoes.  Your podiatrist may recommend a specific type of shoe or padding to help relieve pressure.  Tape or athletic strapping may be used to keep your big toe from moving while it heals. 

Steroid injections are used for severe cases of sesamoiditis.  The medication relieves inflammation.  Some people may need to use crutches and wear a removable short leg fracture brace or a below the knee walking cast for several weeks.  Fractures require immobilization and zero weight bearing for six to eight weeks.

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Surgery

Surgery is rarely used for sesamoid fractures, but in some cases it may be necessary if symptoms fail to respond to non-surgical treatments.  A sesamoidectomy is a surgical procedure to remove the sesamoid bone.  The toe joint may be weaker following sesamoidectomy, making it at risk for bunion formation.

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Recovery

Recovery is individualized and depends on the severity of your condition, whether you have a fracture or sesamoiditis, and the treatment that you receive.  Your podiatrist will let you know what to expect.

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Introduction

Shin splints is a term to describe pain at the front or lower inside edge of the leg.  The pain is most frequently caused by muscle overuse, improper form when exercising, or wearing the wrong type of athletic shoes.  Most cases of shin splints resolve with rest.  In rare cases, surgery may be necessary to treat complications from shin splints.

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Anatomy

Your leg contains two bones.  The larger bone is the tibia, and the thinner bone is the fibula.  The tibialis anterior muscle connects at the front of the tibia.  You use your tibialis anterior muscle to move your foot upward and control the lowering of your forefoot when you walk.  The tibialis posterior muscle attaches at the back inside edge of the tibia and fibula.  You use your tibialis posterior muscle to turn your foot inward and down and lift your heal when walking. 

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Causes

Shin splints is the term for pain that occurs on the front or inside edge of the tibia or "shinbone". 

The pain occurs when the edge of the tibialis muscles pull away from the bone from repeated stress or overuse.  This causes the muscles and the covering of the bone (periosteum) to become inflamed. 

Overused muscles from running or jumping most commonly cause shin splints.  They can occur in athletes that play sports that require quick starts and stops, such as basketball or tennis.  Shin splints commonly occur in people that participate in more athletic activity than their bodies are prepared for.  Shin splints can also result from wearing shoes with poor shock absorption or running on hard surfaces. 

Shin splints are described as anterior or posterior, depending on the muscle groups involved.  Anterior shin splints usually result from using improper form while taking strides or running downhill.  Posterior shin splints are typically related to an imbalance in leg muscles or flat feet.

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Symptoms

Shin splints cause a dull aching pain on the front or inside lower part of the leg.  The pain may increase when you move your legs, climb stairs, or walk.  The pain typically goes away with rest and may be worse when you first wake up in the morning.  The sore area occasionally appears red and swollen.

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Diagnosis

Your doctor can diagnose shin splints after reviewing your medical history and completing a physical examination.  You should tell your doctor about your symptoms, exercise activities, and the types of shoes that you wear.  X-rays will be ordered to rule out stress fractures.  In select cases, a magnetic resonance imaging (MRI) scan may be ordered to show a more detailed view of your tendons and bones.

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Treatment

The majority of shin splints resolve with rest.  It is helpful to stop the activity that caused the condition until your symptoms go away.  Anti-inflammatory medication and cold packs may ease your pain.  In rare cases, cortisone injections are used to treat pain.

Your doctor may recommend shoes that are appropriate for your sport or activity.  If you have flat feet, it may be beneficial to use an arch support.  Specialists can fabricate custom made orthotic insoles for your shoes.

Your doctor may refer you to physical therapy for pain control, rehabilitation, and training tips.  Physical therapists can provide treatments to reduce your pain.  They can teach you how to stretch and strengthen your muscles.  You will also learn correct postures and form to improve your running style and suggestions for avoiding muscle overuse.

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Surgery

In rare cases, surgery may be necessary for complications related to shin splints, such as bone avulsion or compartment syndrome.  Surgery can be required if part of the bone has torn away and needs repair.  A fasciotomy is a surgical procedure used to reduce the pressure in the leg.  Most surgeries are followed by a period of physical therapy

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Recovery

The recovery process is different for everyone.  The length of your recovery period depends on many factors including the extent, type, and location of your injury and the type of treatment that you receive.  Your doctor will let you know what to expect.

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Prevention

You can prevent shin splints by preparing your body before intense exercise with strengthening and conditioning exercises.  Rest when you need to and do not overdo it.  Instead, increase your exercise program gradually.  Use proper form when you walk, jog, or run.  It is helpful to exercise on level surfaces that help to absorb impact.  Make sure that you are wearing the correct athletic shoes, arch supports, or insoles for your activity.

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Introduction

The shoulder can perform movements in more directions and to greater extents than any other joint in our body. But because it can perform so many movements, the shoulder is vulnerable to stress and injury. Shoulder injuries are very common, especially among people who play sports that require overhead arm motions. 

Strong tissues hold the shoulder bones together. The tissues are more likely than the bones to be affected by stress, injury, and “wear and tear.” They may stretch or rupture, causing the shoulder to become weak, unstable, or dislocate. Some shoulder conditions require surgery. Arthroscopy allows surgeons to see, diagnose, and treat problems inside the shoulder joint. 

Before arthroscopic surgery existed, surgeons made large incisions that affected the surrounding joint structures and tissues. They had to open the shoulder joint to see it and perform surgery. An arthroscopy requires small incisions and is guided by a small viewing instrument. Arthroscopy is less invasive than traditional surgical methods. It has a decreased risk of infection and a shorter recovery period.

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Anatomy

Our shoulder is composed of three bones. The Humerus is our upper arm bone. The Clavicle is what we call our collarbone. The Scapula is the shoulder blade that moves on our back. An edge of the scapula, called the acromion, forms the top of the shoulder. There are a total of four joints in our shoulder complex. The humerus and the scapula form the main shoulder joint, called the Glenohumeral Joint. 

Several ligaments connect our shoulder bones together. The ligaments are strong tissues that provide stability. The glenohumeral joint is not a true ball-in-socket joint like the hip. The top of the humerus is round like a ball. It rotates in a shallow fossa (cavity), called the glenoid, on the scapula. A group of ligaments, which form the joint capsule, hold the ball of the humerus in position. In other words, the joint capsule is responsible for holding our arm in place on our body. 

Tendons attach our muscles to our bones. Our muscles move our bones by pulling on our tendons. They move our arms to position our hands for a variety of functions. The Biceps tendon attaches at the front of the shoulder. The Biceps works with other muscles to bend or flex our elbow. The shoulder provides stability when our elbow flexes and as we lift objects. 

The Rotator Cuff tendons connect strong muscles to the humerus bone. These muscles allow the arm to rotate and move upward to the front, back, and side. A structure called the Subacromial Bursa lubricates the rotator cuff tendons allowing us to perform smooth and painless motions. 

We use the rotator cuff muscles to perform overhead motions, such as lifting up our arms to put on a shirt, comb our hair, or reach for an item on a top grocery shelf. These motions are used repeatedly during sports, such as pitching in baseball, serving in tennis, and passing in football.

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Causes

Shoulder problems are very common. Shoulder conditions occur more frequently in the muscles, ligaments, and tendons than in the bones. However, bone degeneration can occur from arthritis. Shoulder problems can occur from injury, “wear and tear,” disease, or aging. Arthroscopic surgery is used to treat shoulder instability, dislocation, impingement syndrome, rotator cuff tears, and some fractures.

Shoulder instability can occur when the muscles, ligaments, or tendons are over stretched or become weak. In some cases, one of the shoulder joints may move or be forced out of its position causing the shoulder to dislocate. 

The glenohumeral joint is vulnerable to dislocation because it is not a true ball-in-socket joint. In severe cases, the muscle may even detach from the bone. The Biceps muscle, in particular, is prone to pulling away from the Glenoid bone under sharp force, such as from extreme weight lifting. 

The rotator cuff is a common source of shoulder pain. The risk of rotator cuff damage increases with age. The aging process can cause the tendons and muscles to degenerate and weaken. This can also result from sudden shoulder movements or overuse, such as pitching in baseball. 
Sometimes the aging process can cause bone spurs to grow on the scapula, particularly in the acromion area. 

Shoulder impingement syndrome occurs when bone spurs or bursa inflammation narrows the space that is available for the rotator cuff tendons. The tendons can tear as they rub across the bone spur, particularly when the arm is elevated. Irritated tendons may develop tendonitis, a painful condition. Often the pain comes from tendon degeneration, similar to the process in tennis elbow. Shoulder impingement syndrome may even cause the tendons to detach from the top of the humerus.

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Symptoms

A shoulder condition can cause your shoulder to feel painful, stiff, and weak. The pain may be bothersome at night and disrupt your sleep. If your shoulder is unstable, it may feel like it pops out of place when you move it. You may have difficulty elevating your arm or performing shoulder movements. You may experience pain and weakness if one of your rotator cuff tendons is torn. However, not all tears are painful. 

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Diagnosis

A doctor can evaluate your shoulder by performing a physical examination and viewing medical images. Your doctor will ask you about your symptoms and medical history. You will be asked to perform simple movements to help your doctor assess your muscle strength, joint motion, and stability. 

Your physician will order X-rays to see the condition of the bones in your shoulder and to identify arthritis or bone spurs. Sometimes a soft tissue injury does not show up on an X-ray. In this case, your doctor may order a Magnetic Resonance Imaging (MRI) scan. A MRI scan will provide a very detailed view of your shoulder structure. Like the X-ray, the MRI does not hurt and you need to remain very still while the images are taken.

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Treatment

Most shoulder conditions can be treated with non-surgical methods. Treatments may include physical or occupational therapy and anti-inflammatory medication to reduce pain and swelling. Cortisone injections may sometimes be helpful. Arthroscopy is recommended when such treatments have provided minimal or no improvement of your symptoms. Arthroscopic surgery is commonly used to reconstruct ligaments or remove damaged tissue and bone spurs. In some cases, both arthroscopic and open surgery techniques are used. Your doctor will discuss your examination results and help you decide on your course of treatment.

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Surgery

Almost all of arthroscopic shoulder surgeries are performed as outpatient procedures. You will require anesthesia for the surgery. 

Your surgeon will make several small incisions, about ¼” to ½” in length, near your joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert the arthroscope and may reposition it to see your joint from different angles. 

During the surgical treatment, your doctor may make additional small incisions and use other slender surgical instruments. In some cases, a procedure called Thermal Capsulorrhaphy is used to treat tendons and ligaments with heat. Because the surgical incisions are so small, they will require just a stitch or Steri-Strips and will then be covered with a bandage.

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Recovery

Your shoulder will need several weeks to heal from the surgery. Your surgeon will restrict your arm movements for a short period of time following your procedure. You will most likely wear an arm sling. The length of time necessary depends on the procedure performed. An occupational or physical therapist will gently help you move your arm at first, and then you will progress to strengthening exercises. 

Generally, most individuals regain functional movement and strength by four to six months after surgery. Your recovery time will depend on the extent of your condition and the amount of surgery that you had. Your surgeon will let you know what to expect. 

Overall, arthroscopic shoulder surgery requires a shorter length of time for recovery than open joint surgery. It also has a reduced risk of infection and causes less pain and stiffness because only small incisions are used and less surrounding tissue is affected or exposed. Most individuals achieve good results.

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Prevention

It is helpful to exercise to maintain a strong, stable, and flexible shoulder. Avoiding repetitive overhead movements may help to prevent certain conditions from worsening. Further, it is important to follow your doctor’s instructions for any weight lifting or motion restrictions

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Introduction

Shoulder impingement syndrome is a painful condition in the shoulder.  It occurs when the tendons in the shoulder are irritated, inflamed or degenerated from repetitive overhead motions or structural abnormalities in the shoulder.  Shoulder impingement syndrome is treated with activity modification, medication, and therapy.  When non-surgical options fail, surgical treatment may be used to relieve symptoms and restore function.

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Anatomy

Your shoulder is composed of three bones.  The humerus is your upper arm bone.  The clavicle is your collarbone.  The scapula is the shoulder blade that moves on your back.  A prominent edge of the scapula, the acromion, forms the top of the shoulder.

The head of the humerus is round.  It rotates in a shallow basin on the scapula called the glenoid.  A group of ligaments, called the joint capsule, hold the head of the humerus in position.  Ligaments are strong tissues that connect bones and provide stability.  In other words, the joint capsule is responsible for holding your upper arm in place at your shoulder.

Four muscles at the shoulder form the rotator cuff of tendon that connects to the head of the humerus.  The muscles allow the arm to rotate and move upward to the front, back, and side.  A gliding membrane, the bursa, lubricates the rotator cuff tendons and reduces friction around them when they move. 

You use your rotator cuff muscles whenever you perform overhead motions, such as lifting your arms up to put on a shirt or reaching for an item on a shelf.  These motions are used repeatedly during sports, such as serving in tennis, pitching in baseball, stroking in swimming, and passing in football.  Overhead motions may also be used for job duties, such as for construction.

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Causes

Impingement syndrome usually occurs as a result of muscle imbalance around the shoulder that place increase stress on the rotator cuff tendons.  Secondary impingement syndrome results from the rubbing or pinching of the tendons and bursa during repetitive overhead movements. Shoulder impingement syndrome occurs when the space beneath the acromion is too small for the rotator cuff tendons.  The space may be too narrow because of structural abnormalities in the shoulder bones, bone spurs, or thickened tissues. 

As the tendons and bursa rub together during movement, it causes friction, pain, and limited motion.  Degenerated tendons can become painful.  Tendons may develop tendonitis, and the bursa may develop bursitis.  Both are painful conditions.  Continued inflammation can cause the rotator cuff tendons to tear or detach from the top of the humerus.

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Symptoms

Shoulder impingement syndrome causes a generalized aching pain in the shoulder and upper arm.  You may feel weakness and pain when you raise your arm for activities, such as combing your hair or putting on a shirt.  Pain at night is typical and may interfere with sleep.

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Diagnosis

Your doctor can diagnose shoulder impingement syndrome by reviewing your medical history and examining your shoulder.  X-rays are ordered to check for bone spurs or acromion abnormalities.  A magnetic resonance imaging (MRI) scan may be used to show more detailed pictures of your shoulder, particularly the rotator cuff, the muscles and joint capsule.

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Treatment

Treatments for shoulder impingement syndrome include rest from the irritating activity and ice packs or medication for pain and inflammation.  Cortisone injections are often used.  Physical therapy is very often used to regain motion and strengthen weakened muscles, thereby decreasing pain.

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Surgery

Surgery is recommended when non-operative treatments have provided minimal or no improvement of your symptoms.  Surgery may be necessary to enlarge the space beneath the acromion to allow the tendons to glide freely, or to trim degenerated tendon.  This can be accomplished with surgery to remove bone spurs and the undersurface of the acromion (acromioplasty), remove some of the bursa, and occasionally a small part of the clavicle.  The surgery is typically performed arthroscopically.

During an open surgical repair, the surgeon makes a three or four inch incision over the shoulder to access the joint.  Arthroscopic surgery is a less invasive surgical procedure.  It uses an arthroscope and narrow surgical instruments that are inserted through small incisions.  An arthroscope contains a lens and lighting system that allow a surgeon to view inside of a joint.  The arthroscope is attached to a miniature camera.  The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape. 

With arthroscopic technology, your surgeon will not need to open up your joint fully.  The arthroscope can be used to remove bone spurs and excess bone.  It can also be used to repair torn tissues.

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Recovery

Arthroscopic surgery usually leads to less pain in the early post operative period.  It has a reduced risk of infection, less blood loss, and less pain and stiffness because only small incisions are used and less surrounding tissue is affected or exposed.  The recovery process is different for everyone, but typically it takes several months to recover from surgery with participation in rehabilitation therapy.  Your doctor will let you know what to expect.

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Introduction

Skier’s Thumb is an injury that occurs when the ulnar collateral ligament of the metacarpal phalangeal joint of the thumb is injured. The ligament can be injured when the thumb is bent back away from the fingers (hyperextended). A sports injury, such as during a fall from skiing, can cause Skier’s thumb. It is treated with immobilization or surgery. Cases that receive prompt treatment tend to have the best outcomes.

This injury was formerly known as Gamekeeper’s Thumb, due to stretching and tearing of the ligament from breaking the neck of small animals during hunting.

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Anatomy

The head of the first metacarpal bone and the base of the proximal phalanx in your thumb meet to form the metacarpophalangeal (MCP) joint. Strong ligaments on each side of the MCP joint stabilize it from side to side. The ulnar collateral ligament attaches to the web space side of the MCP joint. The ulnar collateral ligament is used whenever you hold an object.

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Symptoms

Skier’s Thumb causes pain and swelling. Your skin may bruise and appear discolored. Your MCP joint may feel weak when you pinch, grasp, squeeze, or hold objects. A ruptured ligament may form a Stenner lesion near the base of the thumb on the palm side of your hand. This appears as a bump or thickening in the region of the ligament.

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Diagnosis

Your doctor can diagnose Skier’s Thumb by examining your thumb and performing X-rays that can reveal an avulsion fracture. Stress X-rays can aide the diagnosis by indicating joint instability. You may receive a local anesthetic prior to the test because it can cause pain.

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Treatment

If your ligament is partially torn, your thumb may be immobilized with a thumb spica splint or cast to help it heal. Following casting, you may need to wear a thumb spica splint during activities. Hand therapy rehabilitation can help you strengthen your grip and regain motion.

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Surgery

Surgery is recommended for complete ligament tears and avulsion fractures. Ligament tears are repaired with sutures in an outpatient surgery. The ligament generally tears from the proximal phalanx, so repair involves reattaching the ligament to the bone. There are several methods to do this. Avulsion fractures are repaired with surgical hardware to hold the bone fragment in place. Surgery is followed by hand therapy rehabilitation.

Delayed treatment for a complete ligament tear usually requires reconstruction of the ligament with some type of graft as the condition of the ligament is too poor to allow direct repair.

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Recovery

Skier’s Thumb injuries that receive prompt treatment have the best outcomes. A person that receives surgical treatment for Skier’s Thumb can typically resume normal activities in about three months. Skier’s Thumb injuries that are not treated are at risk for developing arthritis and chronic instability.

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Prevention

You may be able to prevent further injury and impairment by receiving prompt medical treatment for Skier’s Thumb injuries. Injuries that receive early treatment tend to have the best outcomes.
You should adhere to your splint-wearing schedule and perform your home exercise therapy program. 

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Introduction

Sprains and strains are common injuries that can happen to anyone, but occur most frequently in people who participate in sports, perform repetitive activities, or are at-risk for falls.  Sprains involve the tissues that connect bones together (ligaments).  Strains involve a different group of tissues, muscles and the tendons that connect muscles to bones.  Mild sprains and strains can heal with rest and home care.  Significant sprains and strains may require rehabilitation, surgery, or both.

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Anatomy

Your skeleton is made up of bones of all sizes and shapes.  Some bones form joints that allow movement.  Muscles are strong bands of tissue that contract and relax to move bones.  Muscles are attached to bones by tendons, a fibrous tissue.  Some bones in the body are connected together by ligaments, strong tissues that provide stability and support. 

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Causes

Sprain
A sprain describes an injury to a ligament that connects two bones.  A ligament can stretch or tear if the bones in a joint move out of position from a force, such as a fall or direct contact with another person during sports.  For example, an ankle or wrist sprain can result from a fall.

Strain
A strain describes an injury to a muscle or tendon.  Muscles and tendons can be injured from overuse, overstretching, repetitive motions, sports injury, or a direct force, such as from being hit.  For example, back strain may occur in people who perform repetitive heavy lifting.

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Diagnosis

A doctor can diagnose a sprain or strain by physical examination.  Your doctor will ask you to move your joint and test your muscle strength.  X-rays may be taken if a fracture is suspected. 

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Treatment

Immediately following your  injury, you should elevate your joint and apply cold packs to prevent swelling.  Your doctor will formulate a treatment plan based on the severity and degree of your injury.  Mild sprains and strains may benefit from physical or occupational therapy following injury.  More significant sprains and strains may require surgery or immobilization with a brace or splint for healing.

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Am I at Risk

You may be at risk for strains and strains if: 
• Your body is deconditioned or overweight 
• You participate in sports, dance, or other challenging physical activities
• Your job duties entail repetitive movements 
• You have experienced a strain or sprain before 
• You are at-risk for falls

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Complications

Sprains and strains may be prevented by exercising and eating wisely to keep your body fit and healthy.  You can help prevent sprains and strains by warming up and cooling down, respectively, before and after exercising.  Be sure to wear the proper shoes and safety equipment for the sports or job duties in which you participate.  Older adults should discuss fall-risk prevention with their doctors.

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Introduction

Stress fractures are tiny hairline breaks in the bone.  They tend to develop in the legs or feet of dancers, athletes, or military personnel who exercise when their muscles are fatigued or when their bodies are not yet conditioned to the activity level.  Rest and physical therapy can help most stress fractures heal.  Surgery is used in select cases.

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Anatomy

Your leg contains two bones.  The larger bone, commonly called the shinbone, is the tibia.  The thinner bone on the outer side of the leg is the fibula.  The fibula is a common site of stress fractures. 

Stress fractures also tend to occur in certain bones in the feet.  Stress fractures commonly occur in the heel (calcaneus), the midfoot (navicular bone), and second and third metatarsals.  The metatarsals are long bones in the forefoot that attach to the toes.

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Causes

High impact, overuse, or improper form during sports or movements cause stress fractures.  Stress fractures occur from repeated stress to the bones.  Because of the repetitive stress, the bones are not able to repair themselves.  In some cases, the bones may be already weakened by disease, such as osteoporosis, and be vulnerable to fracturing.

People that begin a strenuous exercise routine before they are conditioned or over train to the point of significant fatigue are at risk for stress fracture.  Using improper form during exercise or sports or inadequate sports equipment and shoes can cause stress fractures.  Dancers, military members in initial training, and athletes that participate in high impact sports are at risk for stress fractures because of jumping, running, and marching.

Females have a higher risk because of the effects of hormones on muscles and ligaments.  Tall people, those with leg length discrepancies, and cigarette smokers also have a higher risk.  Some people have an inherited predisposition for stress fractures.

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Symptoms

Stress fractures cause gradual pain that becomes progressively worse with activity.  Rest may relieve pain, although night pain is common.  The top of your foot or outside of your ankle may become swollen, bruised, or tender.

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Diagnosis

If you suspect that you have a stress fracture, you should try to keep weight off of your foot until you see the doctor.  A doctor can diagnose a stress fracture by reviewing your medical history and examining you.  You should tell your doctor about activities that may have contributed to your fracture.

An X-ray or bone scan will be used to create an image of your bones to confirm the fracture.  Fractures typically do not show up on X-rays until later, so a bone scan, which is more sensitive, may be used.  MRI scanning is an excellent method for diagnosing stress fractures not seen on plain x-rays.

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Treatment

Rest is the primary treatment for most stress fractures.  Your doctor may prescribe medications to relieve pain.  Depending on the site and extent of the fracture, periods of rest and activity modification can range from 4 to 12 weeks.  You may need to use crutches when you walk to keep weight off of your foot.  Your doctor may recommend a rigid soled shoe or removable fracture brace.  Some fractures may require casting.

At the appropriate time, you may be referred to physical therapy for rehabilitation.  Physical therapists can teach you exercises to strengthen and balance your muscles, as well as overall general conditioning.  Aquatic therapy is great for conditioning because the buoyancy of the water removes stress from the legs and feet.

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Surgery

Surgery is used for select fractures that do not otherwise heal, or in areas that typically heal more slowly.  Surgical hardware, such as screws or fixation devices, is placed internally to position the bones while they heal.  Bone grafting may be used in some cases.

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Recovery

Recovery times depend on the extent of your stress fracture and the treatment you receive.  Surgical treatments can require up to several months of healing time.  Non-surgical treatments typically have a shorter recovery period.  Recovery is an individualized process, and your doctor will let you know what to expect.  As your condition improves, your doctor will increase your activity level.

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Prevention

You can help prevent stress fractures by wearing the appropriate athletic shoes for your activity.  Make sure to not overdo training or exercise.  Rest, especially when your muscles are tired.  Condition your body for “spring training” before participating fully in any sport.  Stop smoking, and eat a healthy well-balanced diet.

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Introduction

A swan neck deformity occurs when the structures that keep the middle joint of your finger from bending back too far are injured, stretched or weakened. The injury causes the middle finger (proximal interphalangeal) joint to hyperextend. This situation causes an disturbance in the tendon system causing the end finger (distal interphalangeal) joint to bend (flex). This makes the finger appear crooked.

A swan neck deformity can cause pain and loss of function. It is most commonly caused by rheumatoid arthritis. Treatments include splinting, hand therapy, and surgery.

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Anatomy

Your fingers are made up of three bones called phalanges. Two joints separate the phalanges. The distal interphalangeal (DIP) joints are located near your fingertips. The proximal interphalangeal (PIP) joints are located in the middle of your fingers. 

The extensor tendons attach to your phalanges and allow your fingers to extend (straighten). Ligaments attach your bones to each other. The volar plate is a strong fibrous structure located on the palm side of the PIP joint. It functions to prevent hyperextension of your PIP joint.

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Causes

A swan neck deformity occurs when the volar plate becomes torn, weakened, loose, or stretched. When the volar plate is affected, the PIP joint bends back too far and hyperextends. This causes the DIP joint to bend towards the palm of the hand in flexion. The result is a crooked finger with the characteristic swan neck deformity.

Chronic inflammation from rheumatoid arthritis is the most common cause of swan neck deformity. Trauma or neurological conditions, such as cerebral palsy, stroke, Parkinson’s disease, and traumatic brain injury, can cause finger muscles to tighten and stretch the volar plate.

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Symptoms

A swan neck deformity can cause your finger joints to feel painful and swollen. Your PIP joint will bend back too far in hyperextension and your DIP joint will bend in towards the palm of your hand. Finger function can be affected when the deformity is not flexible. Your finger will look crooked.

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Diagnosis

Your doctor can diagnose a swan neck deformity by examining your hand. X-rays will be taken to show joint alignment, joint damage, and to rule out fractures.

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Treatment

Some swan neck deformities can be treated with splinting and hand therapy. This works bests for finger joints that are flexible and not stiff. A hand therapist will show you exercises to stretch and strengthen your joints to gain function. Splinting is usually tried for at least six weeks. 

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Surgery

Surgery may be necessary to reconstruct the skin, tendons, and ligaments that support the PIP joint. If the PIP joint is very damaged, an artificial joint may be surgically implanted to help restore movement, along with proper tendon balancing. This procedure is called Arthroplasty. In some cases, the bones in the finger may be surgically fused together and kept from moving. All types of surgery are followed by splinting and hand therapy rehabilitation.

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Recovery

A full recovery from swan neck deformity surgery can take up to six months. Recovery times for nonsurgical treatments can be from 8 to 12 weeks. Recovery is individualized and your doctor will let you know what to expect.

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Prevention

You should contact your doctor if you notice that you are developing a swan neck deformity. In many cases, early treatment is associated with the best outcomes. Following treatment, your hand therapist can recommend ways to perform your regular activities to help you avoid future injuries. You should participate in your home exercise program and wear your splint as instructed.

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Introduction

Tennis Elbow is a condition that results in deterioration of the tendon fibers that attach to the bone at the outside of the elbow. Tendons are strong fibers that attach muscles to bone. They are tissues that do not stretch easily and are susceptible to degeneration under repeated or traumatic stress. Another name for Tennis Elbow is Lateral Epicondylitis. The pain of Tennis Elbow occurs primarily where the tendons of the forearm muscles attach to the elbow bone at the Lateral Epicondyle. Playing racquet sports is only one cause of Tennis Elbow.

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Anatomy

A tendon anchors the forearm muscles to the outer (Lateral) side of the elbow bone (Epicondyle). The forearm muscles, particularly one called the Extensor Carpi Radialis Brevis, work together to raise the hand at the wrist joint. These forearm muscles are called the “wrist extensors” because they allow the hand to move upward or extend, such as when making the hand motion for “stop.” Repeated use of the wrist extensors can cause microscopic tears in the tendon. Individuals with tendon tears or degeneration can develop forearm muscle weakness along with swelling and pain at the outside of the elbow.

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Causes

Tennis Elbow most commonly occurs in individuals between the ages of 30 and 50 years old. Tennis Elbow is caused by chronic stress to the forearm muscles, especially the Extensor Carpi Radialis Brevis. The repeated motions and stress can cause the tendon to degenerate (tendonopathy). As the name Tennis Elbow implies, playing tennis or other racquet sports is one cause of the condition; particularly, repeated use of the backhand stroke, forearm stroke, or serve with poor athletic form. Many individuals develop Tennis Elbow for no identifiable reason.

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Symptoms

Individuals with Tennis Elbow frequently experience severe burning pain and tenderness at the outer side of their elbow and forearm. In most cases, the pain starts out slow and mild but gradually increases over weeks or months. The pain may increase with movement or when pressure is applied to the outer elbow area. Some individuals experience morning stiffness, muscle weakness, and aching throughout the day. They may be unable to perform the motions necessary to complete various tasks. Some individuals may even feel pain when they are not moving their arm.

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Diagnosis

A physician will perform an examination and review the individual’s medical and activity history to make a diagnosis of Tennis Elbow. The physician evaluates the forearm structures by using simple tests. The history and examination, supplemented with X-rays of the elbow are sufficient to make the diagnosis. X-rays may be used to assess if the elbow bone was injured and help rule out other possible causes of elbow pain, such as arthritis. When taking an x-ray, a camera focuses on the elbow area and a picture is taken. Magnetic Resonance Imaging (MRI) scans are rarely used to diagnose Tennis Elbow however MRI scans may be used to provide a very detailed view of the tendon injury. The MRI equipment takes images by focusing on the elbow area. Both imaging techniques are painless and require that the individual remain very still.

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Treatment

Most cases of Tennis Elbow respond to non-surgical treatments. Treatment typically includes rest or activity restriction/alteration. Specific exercises, often under the guidance of a therapist, are often prescribed. Physicians may instruct the application of ice to the affected areas or recommend medication to relieve pain. Wrist splints and forearm bands can be used to relieve symptoms and promote healing.

Tennis Elbow may also be treated with corticosteroid medications. Corticosteroid medication is a relatively safe pain reliever and in the case of tennis elbow would be injected at the outside of the elbow. After the pain is relieved, physical or occupational therapy may be needed. The physical or occupational therapists focus on improving physical functioning for participation in activities. The therapies address muscle strength, flexibility, endurance, and coordination. This method is successful for many individuals with Tennis Elbow.

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Surgery

The majority of individuals with Tennis Elbow do not require surgery. Surgery is considered if significant pain continues after at least six months of treatment. The surgery is performed as an outpatient procedure. The individual may remain alert with regional anesthesia or be sedated for the surgery. The surgeon makes a small opening at outside of the elbow bone and then removes any injured tissue and reattaches the tendon to the bone. Recently, an arthroscopic surgery method has been developed. Arthroscopic surgery uses a small camera, called an arthroscope, to guide the surgery. Only small incisions need to be made and the joint does not have to be opened up fully. This technique can provide a positive outcome and a shortened recovery time.
 

Following surgery, the elbow is placed in a small splint. After about one week, the individual can begin physical or occupational therapy to stretch the elbow joint and increase motion. Muscle strengthening can begin at about two months after the surgery. Individuals typically return to full activity levels four to six months after surgery. Tennis Elbow surgery produces successful outcomes for the vast majority of individuals.  

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Recovery

With non-surgical treatments, symptoms of Tennis Elbow may be relieved as early as four to six weeks. However, many individuals have chronic symptoms for many months. Individuals requiring corticosteroid injections or surgery may take several months to recover, but typically can achieve good results. Tennis Elbow does not usually lead to severe problems if it is treated. If left untreated, it rarely leads to loss of motion and function.

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Introduction

The thumb joint at the base of the thumb is the most mobile in the hand. The thumb can move up and down, in and out, and rotate slightly to touch the fingers. We move our thumbs hundreds of times each day. The thumb works as a grip when we use a hammer or hold a glass. The thumb also acts as a stabilizer to allow the fingers to manipulate items. We use such precision movements for counting coins and handwriting. Over time, all of the movement and pressure at the thumb joint can cause “wear and tear.” This can result in joint deterioration and arthritis for some individuals. When symptoms are not relieved by non-surgical methods, joint reconstructive surgery, called Arthroplasty, may be appropriate.

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Anatomy

The carpometacarpal (CMC) joint forms where the ends of the metacarpal bone at the base of the thumb and the trapezium bone in the wrist meet also called the basal joint. Smooth cartilage covers the ends of the metacarpal bone and trapezium bone. The cartilage allows the bones to glide easily during motion. Strong ligaments and muscles hold the CMC joint in position and provide stability.

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Causes

The most common cause of CMC joint breakdown is arthritis. It is more common in women after the age of 40. In particular, osteoarthritis can result from “wear and tear” at the joint. Osteoarthritis can cause the smooth cartilage to become rough. When this happens, the bones do not glide easily and moving the thumb may be difficult. In extreme cases, the protective cartilage padding at the ends of the bones may wear away. When the deteriorated joint moves, bone rubs upon bone causing pain, swelling, limited motion, and frequently causing a grinding or popping sensation.

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Symptoms

The most common symptoms of arthritis at the base of the thumb are pain, stiffness, and swelling. These symptoms may appear upon awakening in the morning and then lessen as the thumb “loosens up.” The pain is usually worsened when the joint is moved. The pain typically occurs during and after gripping and pinching activities, such as turning a doorknob, buttoning buttons, tying shoes, or holding a knife to cut vegetables. However, some individuals may experience pain even when they are resting. As the CMC joint begins to break down, it may become weaker and movement may be restricted. If arthritis causes the bones to shift, a “bump” can appear at the outside base of the thumb.

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Diagnosis

Your doctor can diagnose arthritis and CMC joint deterioration by evaluating symptoms. Your physician will conduct a physical examination including examination of your hand and review of your activities, pain patterns, and history of the problem. Your doctor will order an X-ray to see the condition of your bones. When taking an X-ray, a camera focuses on your thumb area and takes a picture. The procedure is painless and simply requires that you remain very still.

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Treatment

In the early stages, arthritis at the base of the thumb will respond to non-surgical treatments involving pain relief and rest. These generally include medications, cortisone injections and splinting. However, because arthritis is a degenerative and progressive disease, it may get worse over time for some individuals. When non-surgical treatments no longer provide relief, surgery may be recommended. Your doctor will discuss appropriate surgical options to help you decide what is best for you.

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Surgery

There are several options for the surgical treatment for arthritis of the thumb CMC joint. One type of surgery, called CMC Arthroplasty, involves reconstructing the joint. The surgery may be done as an outpatient procedure or may require an overnight stay at the hospital. The individual may be sedated for surgery or remain alert with anesthesia that temporarily blocks the feeling in the hand. 

The surgeon has a few options for replacing the joint. The most common procedures involve stabilizing the metacarpal and using one's own tendon tissue as a joint spacer. In one procedure, the ends of the bones are fitted with a prosthetic implant. The surgeon makes an incision at the base of the thumb and carefully opens joint. The surgeon removes damage on the end of either bone, revealing new smooth surfaces. If using an implant with a stem attachment, the surgeon will create a small hole in the bone for placement. Finally, the new joint is reinforced using nearby tendons.

In another joint replacement procedure called Spherical Implant Surgery, a small ceramic ball is placed between the ends of the bones to form a new joint. The surgeon removes the ends of the bones and creates an area for the ball to fit snuggly in the joint. The ball implant allows the bones to glide smoothly.

Following surgery, the thumb is padded and a splint is applied to promote healing. You may experience some discomfort and swelling. Your doctor will recommend some pain medication to help. Keeping the hand elevated above your heart can also help relieve the symptoms. You can do this by placing your hand up on a stack of pillows while you are sitting or sleeping. Physical therapy or occupational therapy with a certified hand therapist is recommended for further casting or splinting. The therapists will work to help you regain motion, strength, and coordination at the CMC Joint.

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Recovery

Full recovery from CMC Arthroplasty will take several months. Joint reconstruction usually requires a period of immobilization followed by therapy. Recovery typically takes up to three months for the prosthetic implant surgery. The casting period is longer as well. Recovery does not take as long for the Spherical Implant Surgery—individuals can return to full activity after three to five weeks. Most commonly, patients continue to improve for many months after surgery. With either surgery method, most individuals achieve good results and are able to use their thumbs with little or no pain.

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Introduction

The tibia, commonly called the shinbone, is located in your lower leg.  A tibia fracture is a common injury.  A fracture is a broken bone.  Vehicle crashes, falls, and sports injuries are frequent causes of tibia fractures.  Depending on the location and type of fracture, treatment involves casting or surgery.

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Anatomy

The tibia is the larger of the two long bones in your leg.  The smaller bone next to the tibia is the fibula.  The top of the tibia is part of the knee joint.  The long length of bone is called the shaft.  The lower part of the tibia helps form the ankle joint. 

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Causes

Tibia fractures can result from vehicle crashes and or falls.  Tibia fractures can occur in people that have been hit by a car.  Jumping or rotating during sports, such as gymnastics, basketball, and football, can cause tibia fractures.  Stress fractures result from prolonged impact from jogging, running, or other repetitive activities. 

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Symptoms

Tibia fractures can cause pain and swelling.  You may not be able to put weight on your leg or walk.  In some cases, the nearby fibula bone is fractured as well.

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Diagnosis

Your doctor can diagnose a tibia fracture by examining your leg and taking X-rays.  Tests that show more detail, such as a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan, may be used as well.  Your doctor will evaluate the nerves and blood vessels in your leg.

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Treatment

Casting can be used to treat tibia shaft fractures if the bones are in good alignment.  Casting is also used for people that are not good candidates for surgery.  A long leg cast that covers the knee and ankle is used to provide support and stability while the bones heal.

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Surgery

There are various types of surgery to treat fractures with bones that have moved out of position or are otherwise unstable.  Intramedullary fixation involves inserting a rod (intramedullary nail) into the center of the bone.  The rod is secured with surgical screws.  The rod provides support while the fracture heals.

Other tibia surgeries include plating and external fixation.  Plating involves securing  a plate and screws into the bone to keep it in proper position while it heals.  Plating is useful for tibia fractures around the ankle or knee .  External fixation uses a frame that is aligned on the outside of the leg and secured with surgical pins to keep the bones from moving while they heal.  External fixation is useful if there are severe skin wounds associated with a fracture. 

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Recovery

The tibia can take a long time to heal, ranging from about four months to over nine months for severe fractures.  Physical therapy may follow casting or surgery.  You will need to use crutches or a walker for a period while you heal.  Your doctor will check your progress with X-rays and gradually increase the amount of weight that you can put on your leg.

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Introduction

Toe fractures can certainly hurt, but they are rarely incapacitating.  They most frequently result from some type of trauma.  The majority of toe fractures can heal without surgery.

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Anatomy

Your toes are part of your forefoot.  Your big toe (hallux) contains two bones (phalanges).  The rest of your toes contain three bones.  Your toes help you balance and walk.

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Causes

Toe fractures are most frequently caused by trauma.  A direct impact, such as dropping an object on the toe, walking into a solid object, or significantly stubbing the toe can break a bone.  Ballet dancers and some athletes are at risk for toe fractures.

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Symptoms

Toe fractures can be very painful.  You may have a sudden intense pain when the bone breaks; followed by pain that may go away.  You may be able to walk, but walking will probably increase the pain.  Your toe may look swollen, bruised, or mishapen.

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Diagnosis

Your doctor can diagnose a fractured toe by reviewing your medical history and injury circumstances, and examining you.  An X-ray or bone scan is used  to see the fracture.

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Treatment

Most toe fractures heal without surgery.  There are many ways to help your toe “rest” so it can heal.  You may wear a toe splint or your doctor may “buddy tape” two of your toes together to provide support and stability.  You may need to wear a rigid walking shoe to protect the toe.

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Surgery

Surgery may be used to realign bones that have broken and moved out of place.  Surgery may be necessary if a fracture involves a joint.  Surgical hardware, such as pins, may be used to hold the bones in place while they heal.

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Recovery

Recovery is individualized and depends on the extent of your injury and the type of treatment you receive.  It can take several weeks for a toe fracture to heal.  Your doctor will let you know what to expect.

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Prevention

It is important to see a doctor if you suspect that you have a toe fracture.  Treatment is necessary to prevent complications such as deformity, chronic pain, loss of use, and bones that fail to heal.

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Introduction

The Triangular Fibrocartilage Complex (TFCC) is a structure that is made of cartilage and ligaments.  It is located on the ulnar side of the wrist (side toward the little finger).  The TFCC stabilizes the bones in the wrist, acts as a shock absorber, and enables smooth movements.  The TFCC may be injured during a fall, sports, or on the job.  An injured TFCC causes pain and may produce a clicking noise when the wrist is moved in certain ways.  TFCC injuries are treated with anti-inflammatory and pain medication, splinting, casting, or surgery.

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Anatomy

The TFCC is located on the ulnar side of the wrist.  It consists of ligaments and two cartilage structures called the triangular fibrocartilage (also referred to as the radioulnar disk) and the meniscus homolog.  Ligaments are strong tissues that connect bones.  Cartilage acts as a cushion and is a smooth surface for the bones in the wrist joint to glide on during movement.  The TFCC stabilizes the radiocarpal joint, the distal radioulnar joint, and the ulnar carpus.

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Causes

The cartilage and ligaments composing the TFCC are prone to degeneration and tearing.  They do not have a good blood supply and therefore, injuries do not heal well.

The TFCC can tear as the result of a wrist injury.  The wrist can be injured during a fall on an outstretched hand.  Forceful twisting and pulling movements can injure the wrist.  This may occur in sports, such as when swinging a bat or hitting a ball with a racquet.  These movements may also take place at work when using tools and equipment.

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Symptoms

TFCC injury causes wrist pain, particularly when moving your hand to the little finger side (ulnar deviation), or turning the wrist to face the hand upward (supination).  Your wrist may feel week and unstable.  Your wrist may catch or not be able to produce smooth movements.  You may hear a clicking noise when you move your wrist.

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Diagnosis

Your doctor can diagnose TFCC injury by reviewing your medical history and examining your wrist.  Imaging tests such as an X-ray or MRI scan will be ordered.  An arthrogram may be conducted in conjunction with an X-ray.  An arthrogram uses a dye injected into the wrist to outline the injured structures on an X-ray. 

Your doctor may use an arthroscope to diagnose a TFCC injury when physical examinations or imaging scans are not conclusive.  An arthroscope is a very small surgical instrument.  An arthroscope contains a lens and lighting system that allows a surgeon to view inside a joint.  The surgeon only needs to make small incisions and the joint does not have to be opened completely.  The arthroscope is attached to a miniature camera.  The camera allows the surgeon to view the magnified images on a monitor screen or take photographs and record videotape.  The diagnostic accuracy of arthroscopy is highly precise.

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Treatment

The treatment that you receive for a TFCC injury depends on your symptoms and the extent of your condition.  Some injuries can be treated with protective supports, such as splints or casts.  Cartilage tears may produce less pain over time even though they do not actually heal.  Your doctor may recommend modalities such as icing, medication, or cortisone injections to ease pain.  Arthroscopic surgery is recommended if nonoperative treatments will not or do not provide symptom relief. 

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Surgery

Arthroscopic surgery is performed as an outpatient.  The anesthesia necessary will be decided by you and your surgeon.  Your surgeon will make a few small incisions near your wrist to insert the arthroscope and thin surgical instruments.  The arthroscope is used to remove torn tissues or to repair the TFCC when possible.  As arthroscopy uses small incisions and is less invasive than traditional surgeries, it has a shorter recovery time with less bleeding, swelling, and pain than open procedures.  Open surgery for TFCC repair is becoming less common with the refinements in arthroscopic techniques.

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Recovery

Recovery is very individualized and your doctor will let you know what to expect.  Your recovery time will depend on the extent of your condition, how it was treated, and when it was treated.  It is common to participate in hand therapy following surgery or cast treatment.

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Prevention

You may be able to reduce the likelihood of TFCC injuries during sports by using correct techniques and the appropriate size racquet or equipment.  If you work in construction or manufacturing, an occupational therapist can make recommendations at your job site to help prevent injuries.

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Introduction

Trigger Finger and Trigger Thumb, medically termed Stenosing Tenosynovitis, are common hand conditions.  This condition occurs when the tendons in the thumb and fingers do not glide smoothly.  Tendons are strong tissues that connect our muscles to our bones.  Trigger Finger and Trigger Thumb causes the tendons to catch or get stuck when the fingers or thumb bend.  This condition makes it difficult to straighten the fingers and thumb back out. It can also cause pain, discomfort, and swelling.  Trigger Finger can occur in one or more fingers or the thumb at the same time, or it may occur in different fingers with or without thumb involvement at different times.

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Anatomy

We have tendons that attach to our thumb and finger bones.  The tendons pass through a tunnel, called a tendon sheath, and connect to the muscles from our forearm.  These muscles allow our fingers and thumb to straighten or extend, such as when our hand is placed flat on a table. 

Normally, our tendons glide smoothly through the tendon sheath allowing for smooth and easy movements.  However, tendons can have difficulty fitting through the tendon sheath if they are swollen or develop a nodule, a small round mass.  The tendon sheath may also swell from irritation, creating a smaller opening for the tendons to fit through.  When the tendon gets stuck in the tendon sheath it can cause pain, swelling, and a popping or catching feeling.  Your finger or thumb may become stuck in one position and may be difficult to bend or straighten.

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Causes

The cause of Trigger Finger and Trigger Thumb is not always clear.  The condition is more common among women than men.  It occurs most often in individuals between the ages of 40 and 60 years old. Trigger Finger and Trigger Thumb develop more frequently in people with certain medical conditions, such as diabetes, rheumatoid arthritis, autoimmune disease, and gout.  Additionally, some individuals may be born with a nodule on their tendon. In some cases, repetitive gripping, such as holding tools, can cause the tendons to become irritated.

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Symptoms

The symptoms of Trigger Finger and Trigger Thumb usually begin with pain and discomfort at the base of the finger or thumb.  You may also feel pain in the palm of your hand. The area may be swollen and you may feel a small lump. 

You will have difficulty bending and straightening your fingers or thumb.  It may feel like they catch or get stuck when you try to move them.  The stiffness and catching may be worse when you first wake up in the morning or after periods of inactivity.  Your fingers or thumb may loosen up with movement.  Your pain may increase when your finger or thumb becomes free. In severe cases, the fingers or thumb can become stuck and unable to move.

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Diagnosis

Your doctor can diagnose Trigger Finger or Trigger Thumb by examining your hand. Your doctor will ask you about your symptoms and level of pain.  Your doctor will feel for any clicking or popping during movement and note any restricted movement.  A locked finger or thumb typically leads to diagnoses of Trigger Finger or Trigger Thumb.

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Treatment

For people with mild symptoms, rest and pain relief may relieve symptoms.  Your doctor may recommend that you wear a splint for support and to promote healing.  Your doctor may suggest over-the-counter pain medication to reduce discomfort and swelling. In some cases, physicians choose to inject an anti-inflammatory cortisone medication into the site.

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Surgery

Surgery is recommended when other treatments have failed or if the thumb or finger is stuck in a bent position.  There are a couple of surgical options, and your doctor will help you decide which is best for you.  One surgery is performed on an outpatient basis.  Your surgeon will numb the area and make a small opening on the palm side of your hand.  Your surgeon will make an incision in the tendon sheath.  This will create a larger tunnel for the tendons to fit through and enable them to glide easily. 

Another option is a procedure that can take place in your doctor’s office.  In some cases, the tendon sheath can be safely opened with the tip of a needle.  This will also create a larger tunnel for your tendons to move through with ease.

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Recovery

Recovery is individualized and dependent on the extent of the condition and the type of surgery performed.  Your doctor will be able to tell you what to expect.  You will be able to move your fingers or thumb immediately following surgery.  You may experience discomfort or swelling for a short period.  A few individuals may require hand therapy to help regain movement, but most people achieve a full recovery in just a few weeks.

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Introduction

Wrist fractures are a very common type of orthopedic injury.  They occur most often as the result of a fall.  When we fall, it is our natural instinct to stretch out our arms in an attempt to cushion ourselves.  However, this causes our full body weight to land on our wrists.  There are several types of wrist fractures that can result from a fall or other source of injury.  The type and location of the wrist fracture determines how it is treated.

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Anatomy

Our wrist has many joints grouped into the Midcarpal Joint and the Radiocarpal Joint.  The joints are composed of several bones in our hand and two bones in our forearm.  The wrist joints function to position our hand and fingers for movement.  
The two bones in our forearm and three bones in our hand form the Radiocarpal Joint.  The bones are connected by muscles and ligaments, which can change the shape of the hand and move the wrist.  The primary motion of the Radiocarpal Joint is to lower the hand and wrist downward and move it towards the little finger side.  We use this motion to grip objects, such as holding on to the handlebars of a bicycle or a steering wheel. 
 
The Scaphoid and the Radius bones are the two most common places for fractures.  The Radius is the widest bone in our forearm.  It is located on the thumb side of our forearm.  The Scaphoid is a small bone in our hand. It is located on the thumb side of the wrist.

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Causes

Wrist Fractures most often result from a fall on an outstretched hand.  As we fall, it is our natural instinct to stretch out our arms in an attempt to cushion our bodies.  However, by doing so, we cause our wrist to receive two forceful impacts.  The wrist contacts the ground first, followed by a second impact of the full weight of our body.  There are several types of wrist fractures that can result from a fall or other source of injury.  The type and location of the wrist fracture depends on position of the wrist during the impact.

Scaphoid fractures occur more commonly in men between the ages of 20 and 40 years old.  Scaphoid fractures are less common in children and older adults.  Falls are the most frequent cause of Scaphoid fractures; however, they are also a common injury from sports and motor-vehicle crashes.  During impact, the Scaphoid will fracture if the wrist is flexed (bent) at a 90 degree angle or greater.  
 
Radius (the widest bone in the forearm) Fractures, also called Colles Fractures, are very common among older adults.  Older women with Osteoporosis, a bone weakening disease, are at the highest risk.
 
Wrist fractures can also occur in children.  Children’s bones are soft and tend to buckle when they break a fall.  These types of fractures in children are called Torus Fractures.

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Symptoms

Symptoms of a Scaphoid Fracture can be mild and differ from person to person.  A Scaphoid Fracture may cause a little swelling but no obvious hand deformity.  You may think that you just sprained your wrist.  However, a Scaphoid Fracture can also cause swelling, pain, or tenderness on the back of the wrist near the thumb side.  Your pain may increase during gripping activities.  Some people experience a deep dull pain that comes and goes during rest.  You may feel tenderness when pressure is applied to an area called the Anatomical Snuffbox.  The Anatomical Snuffbox is a small cup-like depression located on the back of the hand at the base of the thumb. 
 
Colles Fractures can be painful and include swelling just above your wrist.  You may not be able to lift or hold lightweight objects.  Your arm may appear deformed just above the wrist, because of the backward angle of the fractured bone.

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Diagnosis

You should see your doctor as soon as possible if you think you have fractured your wrist.  Your doctor will make a diagnosis by examining your wrist and asking you what has happened to cause the injury.  X-rays will be ordered to provide a good picture of your bones.  

In some cases, doctors may order Computed Tomography (CT Scans) or Magnetic Resonance Imaging (MRI Scans) to get a better view of the wrist structures. These imaging tests are also painless. They require that you remain very still while a camera focuses on your wrist and takes images. CT scans provide a view in layers, like the slices that make up a loaf of bread.  MRI scans provide additional detail of the soft tissues.

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Treatment

Wrist fracture treatments are very individualized and differ from person to person.  The location and type of your fracture will determine what treatment is appropriate for you.  Many fractures can be treated without surgery.
 
Many Scaphoid Fractures are treatable with casting.  However, with modern methods, surgery is generally considered the treatment of choice.  Casting is used to hold your bones in proper placement while they heal.  The cast is usually worn from six weeks to six months.  Most Colles Fractures can be treated with casting or splinting.  The cast or splint is typically worn for about four to six weeks. 

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Surgery

Surgery is recommended for fractures that do not heal properly or when the bones have broken in such a way that they are unlikely to remain aligned when set with a cast.  There are a few options for surgery.  The type of surgery that you have will depend on the location and type of your fracture.  You can be sedated for surgery or your doctor can numb the area with a nerve block. 
 
Surgical options include procedures called an Open Reduction and Internal Fixation or an Open Reduction and External Fixation.  Open Reduction and Internal Fixation refers to techniques that use surgical hardware to stabilize a fracture beneath the skin.  Your surgeon will make an incision and place your bones in the proper position for healing, then secure the bones together with surgical hardware, such as pins, screws, or metal plates.  
 
Open Reduction and External Fixation refers to techniques that use surgical hardware to stabilize a fracture from the outside of the skin.  Your surgeon will make an incision and place your bones in the proper position for healing, then secure the bones with surgical pins that are placed through the outside of the skin.  The surgical pins are attached to a metal frame on the outside of the wrist. 

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Recovery

Physical or occupational therapy follows surgery or casting.  Your therapists will work with you to regain movement, strength, and function of your wrist.   
 
Recovery time from a wrist fracture is different for everyone.  It depends on the type of fracture you had and the type of treatment you received.  Your doctor will tell you what you can expect.

Generally, wrist fractures take several weeks to heal.  Full recovery of motion and strength takes several months.  Most people have good outcomes and regain good use of their wrists.

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Prevention

There are several things that you can do to help prevent falls and decrease your risk of sustaining a wrist fracture.  A general physical examination could identify medical conditions that are associated with balance disorders or dizziness.  An early diagnosis may allow for optimal treatment.

It can be helpful to have an occupational therapist, a physical therapist, or a family member help you examine your home and remove obstacles that may cause you to trip.  It may be helpful to install railings on steps or in your shower.  Low-heeled sturdy shoes may help you maintain proper foot positioning.  A cane or walker may aid your balance while you stand or walk.

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