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Patient Education

Acromioclavicular Joint Pain

Common causes are arthritis and synovitis, also called osteolysis. There is a small joint between the bones of the clavicle and the acromion, which is covered with articular cartilage and surrounded by a synovial membrane which makes fluid.

Over time, wear and tear can cause the surfaces to wear down on the joint, which leads to the development of acromioclavicular joint arthritis.

Many people will develop at least some arthritis with normal aging, however, in some cases, the arthritis may become painful, which may also follow an aggravating injury.

This may also lead to bone spurs which may protrude inferiorly, and put pressure on the rotator cuff tendon and cause rubbing or impingement. In a second group of patients the cause of pain in the acromioclavicular joint is due to synovitis.

These patients are often younger than the patients who develop degenerative arthritis. Synovitis is commonly seen in patients who are performing repetitive lifting activities, particularly in weight lifters doing heavy bench presses or overhead press activities. This can lead to an irritation of the joint, which results in significant swelling and pain.

In contrast to acromioclavicular joint arthritis, where the space between the bone is generally decreased on x-rays, the space with synovitis or osteolysis remains the same or actually increases. In severe cases the bone can start to dissolve away, resulting in cysts in the bone and ultimately destruction of the bone.

The treatment for these two problems is similar. This includes rest, ice, anti-inflammatory medications, and consideration of a corticosteroid injection into the joint. An MRI scan may be helpful in diagnosing acromioclavicular joint arthritis, and particularly in diagnosing acromioclavicular joint synovitis or osteolysis.

With synovitis, increased fluid is commonly seen in the acromioclavicular joint, and there may also be fluid in the distal clavicle and some evidence of bone destruction. In many cases, symptoms can be well controlled with conservative measures.

In other cases, the symptoms will persist, and continue to cause limitation in function and inability to do heavy lifting. In these patients, resection of the acromioclavicular joint can be performed arthroscopically. This may be done in conjunction with a decompression surgery of the subacromial space.

Arthritis

Arthritis occurs when the normal smooth articular cartilage lining the joints is damaged. Initially the cartilage becomes rough and thinned, but is still present. In this stage the patients complain of some mechanical type symptoms such as catching, and possibly swelling, and aching type pain which increases with activity.

As the arthritis becomes more severe, and as bone is ultimately exposed, the pain becomes correspondingly more severe. Eventually the patients may have pain with only minimal activity, and even have pain at rest. Arthritis may follow a specific injury which causes damage to the articular cartilage and subsequent progressive deterioration.

Arthritis may also be due to repetitive overuse or minor injury to the joint. Some patients will have a rheumatologic process, such as rheumatoid arthritis or gout, which causes inflammation in the joint and causes the joint to deteriorate. Such a problem will commonly effect multiple joints with a symmetrical location. In some patients, there may also be a genetic component.

Treatment for arthritis depends on the stage of arthritis and the patient’s level of symptoms. In the minor stages, treatment consists of anti-inflammatory medication to reduce inflammation, weight loss if necessary, and activity modification. Some patients also report benefit with over the counter dietary supplements such as Glucosamine and Chondroitin Sulfate.

Several studies have shown that approximately 50 percent of patients taking these supplements may have some improvement in their arthritic symptoms. However these medications have not been well studied since these are not prescription medications.

Moderate exercise is helpful in maintaining strength and range of motion, and may also help to decrease pain. However patients should avoid high impact activities which put increased stresses on the damaged joint surfaces. Bicycle riding, swimming, and isometric strengthening exercises are often helpful in relieving symptoms without causing increased pain.

Injections may be helpful in patients with arthritic problems. Injection of a corticosteroid may be very effective in rapidly relieving pain and inflammation in an arthritic joint. Corticosteroids work rapidly, but the effects are often only temporary, and the inflammation may recur.

Also, repeated corticosteroid injections may result in weakening of the ligaments, meniscus or articular cartilage within the joint. This is less of a concern in patients who already have severe degenerative arthritis, but in patients with less arthritis, it is prudent to limit corticosteroid injections to no more frequently than every three months, and generally to no more than two or three injections total into the joint.

Another option is injections with hyaluronic acid. These go by the trade names of Euflexxa, Synvisc, Hyalgan or Supartz. Euflexxa and Synvisc is a series of three injections and Hyalgan and Supartz a series of five injections given at weekly intervals into the joint.

These medications are generally slower in onset, but give more prolonged symptom relief than is the case for corticosteroids. Not all patients will respond to these injections, but approximately 80 percent will have some response, with an average response being approximately six to twelve months.

Finally another nonsurgical option is Platelet Rich plasma (PRP) treatment. PRP treatment has been shown in clinical studies to provide even greater symptomatic relief than viscosupplementation when given on a once a week for 3 week basis.

Ultimately if the patient is not responsive to nonsurgical treatment then arthroplasty may be required.

Calcific Tendonitis

Calcific tendonitis in the shoulder commonly involves the supraspinatus tendon of the rotator cuff, and less commonly the infraspinatus or subscapularis tendon. It is unclear why some patients develop irritation in the shoulder alone and some people develop irritation with calcium deposits.

The calcium is soft, and it sits in the rotator cuff under pressure. This causes pain with overhead activities, as well as aching pain. Many of these deposits are asymptomatic and are noted on routine x-rays. However, when greater than 1 cm., the deposits may become symptomatic and cause pain.

There are two general presentations for calcium deposits. In the first presentation, the patients present with severe pain, and label the pain as intense as a kidney stone or childbirth. They have limited motion in the shoulder. This is often seen as the calcium deposit is starting to resolve, and many of these patients will do well after a corticosteroid injection.

If the calcium deposit resolves completely and the patient remains asymptomatic, then no further treatment would be required. Other patients have persistent pain after an acute episode, or more commonly present with chronic aching type pain in the shoulder. These patients have chronic calcium deposits. Initial treatment is with exercises, and possibly a corticosteroid injection or anti-inflammatory medication.

If these patients fail to respond, then it is sometimes necessary to proceed with shoulder arthroscopy with removal of the calcium deposit. If there is a large gap of the rotator cuff tendon, then this may need to be repaired at the same time. Sometimes a subacromial decompression is necessary if there is evidence of rubbing of the acromion on the area of the calcium deposit.

Elbow Lateral Epicondylitis (Tennis Elbow)

This is an overuse injury which originates from excessive strain on the forearm extensor musculature as it attaches to the lateral aspect of the elbow. Typical activities such as forceful, repetitive wrist extension or forearm torquing maneuvers can produce this form of extensor tendinitis.

Appropriate orthopedic care would now consist of a conservative management program. This includes the avoidance of abusive activities which involve forceful and repetitive wrist or finger extension, forearm rotation, and forceful grasping.

The prescription of an anti-inflammatory medicine, the use of a counter-force forearm strap, a supervised occupational therapy exercise program including ASTYM, frequent icing to the lateral aspect of the elbow, and possibly even a cortisone injection into the area of maximum point tenderness may be indicated.

If the symptoms are severe enough, a cortisone injection may lead to tremendous pain relief in approximately 80% of patients. On occasion a second injection may be necessary if the inflammation in the elbow extensor tendon persists.

If the patient fails to respond to these conservative treatments then further treatments are available such as Sonorex Treatment, Platelet Rich Plasma Treatment or surgery.

Meniscal Tears

Meniscal tears are a common cause of knee pain. The meniscus is a soft cartilage cushion that sits between the two bones of the knee, and providing cushioning and reducing the stress on the bone and hard cartilage surfaces. There are two menisci in the knee, the inner one called the medial meniscus, and the outer one being called the lateral meniscus.

The inner edge of the meniscus is thin, and is the most common area where a tear will develop. Tears may be caused by a single traumatic event, particularly in young active individuals. Tears may also develop from repetitive trauma, particularly with repetitive kneeling, squatting or flexed knee activities.

Finally, tears may develop in patients who have significant arthritis, which puts increased pressure on the meniscus and eventually leads to tearing. The blood supplied to the meniscus is localized to the outer third of the meniscus, near its attachments and into the lining of the joint.

Therefore once the meniscus tears, there is a limited ability for healing to occur spontaneously. Most meniscal tears will remain symptomatic and will often progressively enlarge over time.

A tear may be suspected on physical examination but is confirmed by the MRI scan. A Grade III signal on MRI scan has a 95% chance of being a true cartilage tear. However, this does not automatically require arthroscopic surgery. As many as 40 percent of patients with torn cartilage (meniscus) can improve clinically without surgery through proper rehabilitation and medical management. This may include but is not limited to:

  • anti-inflammatory medications to control swelling and pain.
  • braces for support and to control swelling
  • drainage of knee fluid and/or cortisone
    injection if needed
  • therapeutic exercises either under supervision
    of a physical therapist or independently after
    proper instruction:

    • this may include low resistance cycling
      to allow the nutrients in the joint
      fluid to penetrate the cartilage and
      encourage healing
    • weight training to develop strength in
      surrounding musculature
    • aerobic conditioning to improve endurance

    A torn cartilage cannot “mend” itself but clinical improvement occurs if the “defective cartilage” no longer irritates the joint. It is possible that sometime later, the knee could again be aggravated by this same cartilage and require treatment.

    Arthroscopic surgery becomes necessary if the knee does not respond to therapy, cannot tolerate the treatment, or symptoms recur frequently. A referral to the most appropriate specialist will be made when necessary.

    The main concern with meniscal resection is the increased stresses on the joint surface, which may lead to progressive arthritis. In patients in whom the meniscus has been totally resected, a significant percentage will develop arthritic changes in the joint by 15 to 20 years after surgery. This arthritic progression so far does not appear to be as much of a problem in patients in whom a partial meniscectomy has been performed, particularly if it is possible to preserve the outer cushioning rim of the meniscus. However, even patients with a partial meniscectomy may go on to develop arthritic changes in the future. The best situation is clearly to have an intact meniscus in the knee.

Osgood-Schlatter’s Disease

This is generally a self-limiting process which occurs in the tibial tubercle at the insertion of the patellar tendon in active adolescents. This is more common in boys than in girls, and is frequently due to jumping or other resisted flexed-knee activities.

This is a problem that occurs because the tendon puts pressure on the growth plate, which then causes irritation in the apophysis in the front of the knee. This can lead to soreness and irritation, and often to overgrowth of the bone in this area. Most of these problems will do well with conservative measures including activity modification, an isometric quadriceps strengthening program, and hamstring stretching.

Once growth has been completed, the symptoms will generally resolve. A small percentage of patients will have a small fragment of bone, called an ossicle, which fails to unite when growth is completed. This may continue to cause pain even into adulthood. This can then require a subsequent surgical removal.

In most cases the patients may continue with activities as tolerated, although they may need to rest if symptoms increase. Patellar tendon strapping and physical therapy can also be helpful. If symptoms become severe, then a trial of a knee immobilizer and rest or possibly even a cast is occasionally necessary.

Patellofemoral Problems

Patellofemoral problems are among the most common problems we see in patients with knee pain. The patellofemoral joint may be injured either from a direct blow to the front of the knee, or more commonly with progression over time from squatting, kneeling, jumping, running or other vigorous flexed knee activities.

The smooth articular cartilage on the patellofemoral joint becomes irritated, and in the initial stages it becomes soft and painful. Over time the softened cartilage can roughen and begin to pull away from the underlying bone.

Another term for this problem is chondromalacia. In a small number of cases, the chondromalacia changes will progress to the point where the cartilage is completely lost from the bone, resulting in significant patellofemoral arthritis.

Patellofemoral problems are particularly common in teenagers, with females affected more commonly than males. There may be some relationship to hormonal changes that occur during puberty, as this is a more common problem in the early teen years than in the later teen years. With increasing age, there is a higher incidence of arthritic change.

Risk factors for this problem include being greater than 10 pounds above ideal body weight, abnormal tracking of the patella within the trochlear groove, abnormal lower limb alignment, including pes plano valgus alignment of the feet, weakness of the quadriceps muscles, hamstring tightness, frequent flexed knee activities, and female gender.

Most patellofemoral problems are treated conservatively without the need for surgery. Conservative measures are often helpful in relieving symptoms, although symptoms may not completely resolve, and may recur. Recurrence is particularly likely in patients who have gone on to develop significant chondromalacia changes or arthritic changes in the patellofemoral joint.

The extensor mechanism controlling the kneecap motion through the femoral groove is a complex one. The importance of a strong and coordinated quadriceps muscle was explained as well as the affect of lower extremity alignment.

The treatment plan must be customized according to all of the unique factors in a given patient. The goal of treatment is to rehabilitate the thigh and surrounding musculature to their optimum performance allowing the most pain free return to activities. This is accomplished through a combination of treatments to include but not limited to:

     

  • Activity modification by avoiding repetitive bending, squatting and stooping, as well as running or ambulation on steep grades. This may diminish the joint reaction forces of the patellofemoral joint, thus reducing the amount of compression and eventually relieving the pain and discomfort in the anterior knee.
  • Anti-inflammatory medications to control pain and inflammation when necessary.
  • Therapeutic exercises either through a custom guided physical therapy program or as a home or gym program.
  • Braces if necessary to control kneecap tracking and to minimize symptoms during activities.
  • Patellar taping if necessary to control kneecap tracking during exercises.
  • Custom foot orthotics to correct lower extremity alignment and minimize patellofemoral forces.
  • There is some evidence that glucosamine/chondroitin sulfate combination nutritional supplements may diminish the amount of joint pain that may be present, although scientifically it has not proven to be much better than placebo in certain studies. I have offered this to the patient. If a trial is attempted I would recommend a total of 1,500/1,200 mg of the combination of glucosamine/chondroitin sulfate for a three-month period of time. If it is not beneficial I would recommend not taking it any longer.
  • The last resort I commonly will offer patients with this particular condition is corticosteroid injections to help diminish the amount of inflammation and swelling within the patellofemoral joint. This is commonly beneficial in relieving the patient’s symptoms. Although transient it can break a pain cycle and allow the individual to be more functional. I would not recommend more than three injections over a one-year period in that there are local effects that can cause soft tissue/collagen breakdown and eventually possible tearing of the structures in the joint.
  • Visco supplementation has also been beneficial in patients with degenerative changes of the medial and lateral compartments and has been released by the FDA for use in these conditions. Commonly, individuals with tricompartmental disease will notice a significant amount of improvement in anterior knee pain with use of visco supplementation, so this may also be an option. If there is a significant amount of degenerative change in addition to malalignment of the patellofemoral joint, this may be an option as well for the above-mentioned individual.

 

There is a 90 percent chance that patellofemoral pain symptoms can be brought under control through these nonsurgical techniques. No exact time frame can be given to predict when improvement will occur, however, 3-6 months of aggressive rehabilitation may be required before considering non-surgical treatment a failure.

Rotator Cuff Tendonitis

The rotator cuff tendons are a small group of muscles deep inside the shoulder which holds the shoulder in place while the deltoid muscle moves the arm up and down. The rotator cuff needs to pass underneath the top of the shoulder or acromion bone as the arm is abducted.

Many patients will develop irritation of the rotator cuff either due to repetitive overhead activities, or trauma to the shoulder such as a fall or sudden pull on the arm. If the rotator cuff becomes irritated, then patients will develop pain with overhead activities, as the rotator cuff rubs underneath the bone with elevation.

This leads to more swelling, more irritation and more rubbing, a condition which causes pain and which is termed an impingement syndrome.

Most patients with impingement syndrome will do well with conservative measures without the need for surgery. This includes a program to reduce inflammation including anti-inflammatory medication, rest, ice and some strengthening exercises with the arm at the side to decrease the shoulder elevation.

A corticosteroid injection may also be helpful in relieving inflammation, and as a diagnostic test to help confirm the diagnosis of an impingement. In some patients the pain will persist despite conservative measures, in which case further evaluation such as an MRI scan is performed.

The MRI scan may show a rotator cuff tear. Small partial tears can often still be treated conservatively, but complete rotator cuff tears or large partial rotator cuff tears which are symptomatic will often require repair.

Surgical treatment of rotator cuff pathology usually includes a subacromial decompression to remove the pressure on the rotator cuff tendon. If the tendon tear is large, then the rotator cuff is re-attached to the bone using either arthroscopic or open techniques.

If a decompression surgery alone is performed to remove the bone spur, and a rotator cuff repair is not necessary, then recovery is fairly rapid with immediate resumption of motion, and approximately a two to three month time until the patient can return to full activities.

When a rotator cuff repair is performed, the patient needs to be in a sling for approximately four to six weeks, and is unable to actively abduct the arm for approximately six weeks. Recovery from rotator cuff tears is much slower, and it may be four to six months until the patient is returned to full function.

For very large tears, recovery time may be greater than one year. Even with repair of a rotator cuff tear, the patient may still have some weakness and loss of motion, although pain relief is generally significant, particularly pain at night.

Shoulder Impingement

Shoulder impingement syndrome is a problem in which the rotator cuff tendon rubs under the acromion, leading to inflammation and pain in the rotator cuff tendon. Most patients with impingement syndrome will do well with conservative measures without the need for surgery, although recovery may take 3-6 months.

Physical therapy is essential to re-train the shoulder to adopt proper mechanics. Corticosteroid injection into the subacromial bursa can help temporarily relieve pain and inflammation. In some patients, the impingement syndrome will progress to an actual rotator cuff tear, or chronic scar tissue will develop, and the patient will develop chronic symptoms. In that case, surgical intervention may be required.

Tendinopathy

It is important to differentiate between tendonitis and tendinopathy. These conditions are often confused by patients as well as by health care providers. The pathophysiology and treatment for these conditions is very different.

Tendonitis refers to inflammation of the tendon. This is often an acute process due to overuse of the tendon. Tendonitis responds well to ice, anti-inflammatories and rest. Bracing or immobilization may be necessary to allow for complete rest of the tendon. Sometimes a corticosteroid injection, into the tendon sheath or the area around the tendon, may be necessary to provide temporary relief from the pain and inflammation.

It is also important to correct the offending overuse activity that caused the tendonitis in the first place in order to prevent a recurrence. Physical therapy is helpful to control pain and inflammation by using therapeutic modalities. Physical therapy is also helpful to address and correct poor musculoskeletal mechanics which may have contributed to the injury as well.

Achilles’ Tendon Conditions

An Achilles tendon is a group of tough fibrous tissue that connects the calf muscles to the heel bone. It functions so as to elevate the heel while walking or running.
The two major problems associated with the Achilles tendon are:

  • Achilles tendonitis: refers to the inflammation of the tendon.
  • Achilles tendinosis: a condition that originates due to degeneration of the tendon caused by the unresolved inflammation. The tendon develops minute tears or pores in the tissue thereby losing its unique structure.

Sometimes, because of degeneration, an Achilles tendon also tears or ruptures either partially or completely causing pain or loss of movement.

Causes:

Constant overuse or repetitive activities can cause Achilles tendon disorders. These activities exert excessive stress on the tendon and lead to microtears. This damage or injury of the tendon results in pain.

People involved in activities like sports and exercises are more prone to develop Achilles tendon disorders. It is also commonly seen in people whose occupation puts lot of pressure on their feet and ankles. Simple movements like running, jumping, stretching, and improper shoes can also result in rupture of the tendon.

Symptoms:

  • Swelling and bruising
  •  

  • Mild or severe pain
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  • Stiffness
  •  

  • Loss of strength
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  • Decreased movements of the ankle
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  • Muscle weakness or tenderness
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  • Difficulty in walking or standing
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Diagnosis:

Diagnosis is based on the following:

  • Medical history
  • Physical examination of the foot and ankle to assess the movements and condition of the tendon
  • Radiological investigations like foot or ankle X-rays, scans or MRI

 

Treatment:

Treatment options depend on the duration and extent of injury to the tendon. Mild cases can be treated by the following approaches:

  • Get adequate rest
  • Start medications as prescribed by your doctor which help relieve pain and inflammation
  • Apply ice bags over a towel to the affected area for about 15-20 minutes to reduce swelling and inflammation
  • Restrict the activities that cause pain and stress for a short duration
  • Immobilization through the use of a cast, splint, brace, walking boot, or other device which prevents the movements of the leg and assists faster healing of the tendon
  • Physical therapy modalities such as strengthening exercises, massage, ultrasound therapy, stretching, and a walking rehab program help to improve range of motion
  • Surgery is indicated only in severe cases and depends on the age and activity level of the individual, extent of damage to the tendon, and other factors

 

Prevention:

Strictly follow the post-treatment instructions and wear appropriate shoes for the foot type and activity as recommended by your doctor to prevent the recurrence of the condition.

Hip Pain

Hip pain, one of the common symptoms patients complain of, may not always be felt precisely over the hip joint. Pain may be felt in and around the hip joint and the cause for pain is multifactorial.

The exact position of your hip pain suggests the probable cause or underlying condition causing pain. Pain felt inside the hip joint or your groin area is more likely to be because of the problems within the hip joint.

Likewise, the pain felt on the outer side of your hip, upper thigh or buttocks may be a result of the problems of the muscles, ligaments, tendons and soft tissues surrounding the hip joint. However certain disease conditions affecting other parts of your body such as lower back or knees also cause hip pain.

The main cause of sudden pain in the hip is an injury resulting in fracture of the hip bone. Hip fractures are common in the elderly individuals because the bones wear out as age advances.

Other causes of hip pain may be arthritis, bursitis, infection, low back pain, osteonecrosis of the hip, sprains or strains, and tendinitis resulting from repetitive use. Your doctor will evaluate the condition based on the medical history, physical examination of the hip and thigh region, and diagnostic tests including X-rays and other scans.

Self-care and pain relieving anti-inflammatory medications offer symptomatic relief. However the exact cause for the pain needs to be addressed. Practicing certain measures can avoid aggravation of pain and also improve the quality of life. Avoiding physical activities that may worsen the pain, stretching the quadriceps and hamstring muscles, performing warm up exercises before actual exercise regimen improve the condition.

Applying ice packs over the region of pain for about 15 minutes three to four times daily reduces both pain and swelling. But if you have an injury with severe hip pain and swelling, talk to your doctor immediately for better treatment outcomes.

Shoulder Pain

Pain in the shoulder suggests a shoulder injury and shoulder injuries are more common in athletes participating in sports such as swimming, tennis, pitching, and weightlifting. The injuries are caused due to the over usage or repetitive motion of the arms.
In addition to pain, shoulder injuries also cause stiffness, restricted movements, difficulty in performing routine activities, and popping sensation.

Some of the common shoulder injuries that cause pain and restrict the movement of shoulders include sprains and strains, dislocations, tendinitis, bursitis, rotator cuff injury, fractures, and arthritis.

  • Sprains and strains: A sprain is stretching or tearing of ligaments (tissues that connect adjacent bones in a joint). It is a common injury and usually occurs when you fall or suddenly twist. A strain is stretching or tearing of muscle or tendon (tissues that connect muscle to bone). It is common in people participating in sports. Strains are usually caused by twisting or pulling of the tendons.
  •  

  • Dislocations: A shoulder dislocation is an injury that occurs when the ends of the bone is forced out of its position. It is often caused by a fall or direct blow to the joint while playing contact sport.
  •  

  • Tendinitis: It is a inflammation of a tendon, a tissue that connect muscles to bone. It occurs as a result of injury or overuse.
  •  

  • Bursitis: It is an inflammation of fluid filled sac called bursa that protects and cushions your joints. Bursitis can be caused by chronic overuse, injury, arthritis, gout, or infection.
  •  

  • Rotator cuff injury: The rotator cuff consists of tendons and muscles that hold the bones of the shoulder joint together. Rotator cuff muscles allow you to move your arm up and down. Rotator cuff injuries often cause a decreased range of motion.
  •  

  • Fractures: A fracture is a break in the bone that commonly occurs as a result of injury, such as a fall or a direct blow to the shoulder.
  •  

  • Arthritis: Osteoarthritis is the most common type of shoulder arthritis, characterized by progressive wearing away of the cartilage of the joint.

Early treatment is necessary to prevent serious shoulder injuries. The immediate mode of treatment recommended for shoulder injuries is rest, ice, compression and elevation (RICE). Your doctor may also prescribe anti-inflammatory medications to help reduce the swelling and pain.

Your doctor may recommend certain exercises to strengthen shoulder muscles and to regain shoulder movement based on the type and severity of injury of following a surgical correction of shoulder injury to regain the strength to the muscles in shoulder.

Stem Cell Therapy

Introduction

Stem cell therapy in Orthopedics is used to help in the repair of damaged tissue by harnessing the healing power of undifferentiated cells that form all other cells in our bodies.

The process involves isolating these stem cells from a sample of your blood, bone marrow or adipose tissue (fat cells), and injecting it into the damaged body part to promote healing. Platelet-rich-plasma (PRP), a concentrated suspension of platelets (blood cells that cause clotting of blood) and growth factors, is also used to assist the process of repair.

Disease overview

Aging, exercise, sports and injuries cause excessive wear and tear of the body. As we age, the process of repair is slowed down due to reduced production of mesenchymal stem cells (repair cells).This causesthe joints’ elastic tissueto becomestiff and lose its elasticity, thereby increasing its susceptibility to damage. This problem can be treated with stem cell therapy, where yourown body’s cells can be used to repair and promote healing of degenerated or injured joints.

Indications

Stem cell therapy in Orthopedics is currently being used in conditions such as:

  • Osteoarthritis (degenerative joint disease)
  •  

  • Chronic tendonitis (inflammation of the elastic tissue that connects muscle to bone)
  •  

  • Bone fractures
  •  

  • Degenerative vertebral discs

Procedure:

Stem cells from your blood, bone marrow or fat cellsare harvestedto treat your joint pain. The treatment plan will depend on your individual condition, but generally, one stem cell injection is administered initially and an injection of PRP is given after four to six weeks.

The steps involved in stem cell therapy include:

  • Your doctor will apply a local anesthetic to the area from which cells will be taken (stomach or hip)
  •  

  • About 30-60cc of bone marrow stem cells or about 20cc of adipose-derived stem cells is extracted.
  •  

  • The stem cells and platelets are then separated from the rest of the blood by spinning it in a centrifugal machine.
  •  

  • Healthy stem cells and growth factors are then injected directly into the damaged area.
  •  

Post-procedural Care

Numbness will persist in the injured area for about an hour; once it lessens you should prevent the area from further injury. Anti-inflammatory medications should be avoided for at least 4 weeks. You can use ice for 10-20 minutes every 2-3 hours if required. Your doctor may prescribe medications to relieve pain. Inform your doctor if you experience bleeding, increased pain, infection or fever.

Risks and Complications

As with any procedure, stem cell injection involves potential risks and complications. The common complications at the injection site include infection and bruising. Soreness may occur at the site from where the stem cells were removed.

Advantages

Advantages of stem cell therapy are:

  • The therapy reduces pain and provides long lasting relief from chronic tendinitis and osteoarthritis.
  •  

  • The therapy uses the body’s own cells for repair therefore there is no chance of rejection.

 

Stem cell therapy is a revolution in relieving joint pain without the need for invasive surgical interventions. It is especially helpful in sports medicine enabling you to return to your sport much earlier than with surgery.

Patient Education

Thank you for choosing Southern California Orthopedic Institute. Our commitment to providing exceptional orthopedic care continues with our patient education interactive videos.

Here, you will find helpful, comprehensive, and interactive patient education videos on a variety of orthopedic conditions, orthopedic surgical procedures, and associated treatment options.

These interactive patient videos are meant to provide a general, educational overview. Please understand that each situation is unique, and no online content can replace one-on-one communication with your doctor.

If you have questions regarding an orthopedic injury, condition, or procedure after viewing the interactive patient education videos, please call Southern California Orthopedic Institute at (818) 901-6600, and our staff will be happy to assist you.

External Resources

Orthobiologics

Platelet Rich Plasma Therapy (PRP) is an emerging treatment in health care known as “Orthobiologics” which uses cutting-edge technology along with nature to accelerate the healing process of many types of orthopedic injuries. Platelet Rich Plasma Therapy is the solution for treating arthritis pain as well as ligament or tendon injuries when traditional methods have failed.

With this therapy, a high concentration of platelets is produced by using a small amount of your own blood. Platelets are the cells which are found in blood that contain bioactive proteins, including growth factors and a small amount of stem cells.

Growth factors play an important role in accelerating the healing of soft tissue injuries at the reparative cell level. The concentrated platelets are injected into the damaged soft tissue, providing500% more platelets and growth factors at the injury site. This accelerates the repair and regeneration of connective tissue and thereby restores you to pre-injury pain levels and increased function faster.

Most patients require more than one injection at an interval of two to three weeks to achieve successful outcomes. Patients are also encouraged to participate in physical therapy to accelerate the rehabilitative process.

Adhesive Capsulitis

This is a condition in which the lining of the shoulder joint becomes inflamed, and subsequently becomes thicker. This causes pain initially, followed by progressive loss in range of motion of the shoulder.

There are two types of adhesive capsulitis. Primary adhesive capsulitis is a rheumatologic type problem, and may follow a minor injury. This results in significant loss of motion over time, with gradual resolution over a two to three year course. This is more common in patients who have hypothyroidism or diabetes, and can also be more difficult to treat in patients with these conditions.

The second type of adhesive capsulitis is secondary to an underlying problem such as a rotator cuff tear or biceps abnormality in the shoulder. The pain from this problem causes the patient to stop moving the shoulder, and a secondary adhesive capsulitis develops.

Secondary adhesive capsulitis will generally regain motion more rapidly, but once motion has been regained, then further treatment may be required for the underlying problem.

The initial treatment is the same for both the primary and secondary adhesive capsulitis, which is an aggressive range of motion program. Most patients will respond well to exercising and stretching on their own, and I also would recommend a course of formal physical therapy for additional help in stretching the shoulder.

If the patient does not improve with this regimen, then manipulation under anesthesia with an intra-articular steroid injection may be necessary. In patients with diabetes or hypothyroidism, or in patients who fail to improve with manipulation alone, then a left shoulder arthroscopy with capsular release and release of the rotator cuff interval may also be necessary.

Anti-inflammatory medication may be helpful in reducing the inflammation, although in general a corticosteroid injection is less helpful than would be the case for a rotator cuff problem.

These problems are often slow to resolve. If the motion improves but the pain persists, then this would make the diagnosis of a secondary adhesive capsulitis more likely, and an MRI scan is performed in these patients to rule out rotator cuff pathology or other underlying shoulder problems.

Bursitis

A bursa is a small sac that lies between tissues to allow tendons to move smoothly over other tissues. A normal bursal sac is usually collapsed with little or no fluid in it. When overuse occurs the bursa can become inflamed and filled with fluid.

The area can be exquisitely tender to touch and very painful to move the corresponding body part. Treatment is directed toward decreasing the inflammation. This can be achieved by oral anti-inflammatory medications, local application of ice, or through different modalities in physical therapy.

These might include ultrasound, phonophoresis/ iontophoresis (cortisone applied topically via ultrasound or electrical current). The strongest anti-inflammatory is cortisone given by injection directly into the bursa.

It is imperative to stop the aggravating activities that led to the bursitis to allow for adequate healing. Exercises are also prescribed to rehabilitate the involved muscles and tendons and help prevent recurrences.

Iliotibial Band (ITB) Syndrome

The iliotibial band is a large sometimes tense band of tendon that originates from the muscle high up on the side of the thigh and attaches on the lateral side of the knee. This tendon can become too tight from overuse and start to rub over the bony prominence on the side of the knee or hip.

It then becomes thickened, inflamed and painful. The treatment is geared to decrease the inflammation and prevent recurrences. Anti-inflammatory medications may be helpful and prescribed accordingly. In severe cases a cortisone injection may be required.

Physical therapy may also be prescribed to include: ultrasound (deep sound waves to heat the tendon), heat and/or ice, phonophoresis (combination of ultrasound and cortisone), iontophoresis (combination of electrical stimulation and cortisone), various stretching exercises and strengthening exercises, ASTYM.

Gait analysis is often required to correct the patient’s running and walking mechanics.

Elbow Medial Epicondylitis

This is an overuse syndrome which originates from excessive strain on both the wrist and finger flexor musculature as well as the forearm pronator musculature as it attaches to the medial aspect of the elbow.

Typical activities such as forceful, repetitive wrist and finger flexion or forearm torquing can produce this form of tendinitis. Appropriate orthopedic care would now consist of a conservative management program.

This includes the avoidance of abusive activities which involve forceful, repetitive wrist and finger flexion, anti-inflammatory medicine, the use of a counter-force forearm strap, a supervised rehabilitation exercise program including ASTYM, frequent icing to the medial aspect of the elbow, and possibly even a cortisone injection into the area of maximum point tenderness.

If the symptoms are severe enough, a cortisone injection may lead to tremendous pain relief in approximately 80% of patients. On occasion a second injection may be necessary.

If the patient fails to respond to these conservative treatments then further treatments are available such as Sonorex Treatment, Platelet Rich Plasma Treatment or surgery.

Morton’s Neuroma

A morton’s neuroma is a benign nerve tumor. In this case tumor refers to a mass as opposed to a malignancy. The neuroma can form in the interdigital nerve of either the 2nd or 3rd web space. It is more common in the 3rd web space over all.

Symptoms can include pain radiating as far proximally as the hip or distally into the toes. Sometimes the pain is poorly localized and sometimes the pain is absent. It is very common for the pain to be so poorly localized that diagnosis may take several examinations over a period of time.

If the nerve is thought of as a electrical cable the purpose of this nerve would be to transmit information from the toes to the brain. Using the same analogy a neuroma would be equivalent to concrete surrounding the nerve at a discrete point usually where the nerve divides into two branches, one to each toe.

In reality it is scar tissue rather than concrete that surrounds the nerve. Pressure on the neuroma causes pain to be transmitted either distally or proximally via the cable that in reality is the nerve.

Treatment of Morton’s neuromas consist of three basic modalities. Occasionally but rarely, a pad placed between the metatarsals, just proximal to the metatarsal heads at the appropriate site can relieve some of the pain.

This is effective if the pain is not severe. Occasionally an injection of cortisone can be helpful. Risks associated with the cortisone injection include discoloration and atrophy of the skin as well as atrophy of the underlying fat pad.

The skin changes and atrophy are permanent changes. The cortisone injection may be ineffective or effective only for a short period of time. I found it to be somewhat helpful in treating athletes in so far as that they occasionally may get by with injection for a period of time to perform at a game, meet or race although the expectation is that it may not necessarily be a permanent solution.

The third option would be surgery. Occasionally, even after surgery, a cortisone injection may be helpful to decrease the inflammation in the web space.

Patellar Dislocations

Patellar dislocations are the most common dislocations in the body. These are often traumatic, although in some patients a spontaneous dislocation can occur. The risk factors for patellar instability include a shallow trochlear groove, a tight lateral retinaculum, increased valgus alignment of the lower leg, an increased Q-angle, and generalized ligamentous laxity.

The patellar dislocation causes pain and swelling, and may also cause damage to the joint surfaces as the patella moves out of place. This may result in some chondromalacia in the patellofemoral joint, and sometimes an osteochondral fracture or osteochondral loose body.

Generally an initial patellar dislocation is treated conservatively, with a strengthening program and knee support. Many patients will be able to do well without further dislocations if they can maintain their quadriceps strength.

The younger the patient age at the time of the first dislocation, the higher the risk of recurrent dislocation. Patients involved in cutting, pivoting and twisting activities are also more likely to sustain a recurrent patellar dislocation. Recurrent episodes of instability not only affect performance, but may also lead to further damage to the knee joint.

Generally recurrent patellar dislocations are treated with surgical stabilization. If the patient sustains a significant fracture of the patella or a loose body is present, then surgery is generally performed to remove the loose body and/or to stabilize the fracture.

Surgical options include arthroscopy with lateral retinacular release alone, and/or repair of the medial retinaculum with or without lateral release, and a distal re-alignment.

Plantar Fasciitis

Plantar fasciitis is a chronic condition caused by inflammation of the plantar fascia at its insertion into the anteromedial calcaneal tuberosity. Occasionally the body of the plantar fascia itself can be inflamed and the pain therefore can extend from the heel towards the mid and forefoot.

The condition is generally caused by overuse but can certainly occur in a multitude of situations including athletics, obesity, pregnancy, systemic arthropathy such as Reiter’s disease, initiation of exercise, industrial exposure. The pain can last a long period of time and generally resolves within nine to eighteen months.

Treatment consists of three stages. The first stage includes icing, using ice massage technique, stretching using a technique consisting of toe and heel pointing while still in bed followed by heel cord stretches, Visco elastic heel cups and anti-inflammatory medicine if this is indicated for the particular patient.

The second stage consists of Cortisone injection, orthotics, night splints, and other modalities, including the use of physical therapy. Another treatment option of a conservative nature for this patient would be a possible orthopedic lithotripsy (Sonorex) or Platelet Rich Plasma (PRP)treatment to help reduce the pain and discomfort and initiate a healing response.

The last stage, which is not commonly needed consists of surgery. Surgery includes the release of the medial 2/3 of the insertion of the plantar fascia through a plantar incision. The indications for surgery are the failure of conservative treatment and prolonged symptoms.

Sever’s Disease

This is generally a self-limiting process which occurs in the calcaneus at the insertion of the achilles tendon in active adolescents. This is more common in boys than in girls, and is frequently due to jumping or other activities.

This is a problem that occurs because the tendon puts pressure on the growth plate, which then causes irritation in the apophysis in the heel. This can lead to soreness and irritation.

Most of these problems will do well with conservative measures including activity modification and heel cord stretching. Once growth has been completed, the symptoms will generally resolve.

In most cases the patients may continue with activities as tolerated, although they may need to rest if symptoms increase. Physical therapy can also be helpful. If symptoms become severe, then a trial of crutches and rest or possibly even a cast is occasionally necessary.

Shoulder Instability

The shoulder is the most mobile joint in the body, with a flat socket and a round head. There is little intrinsic stability in the shoulder joint, and the stability is maintained by ligaments.

There are two types of shoulder instability. There is a traumatic unidirectional instability, when the shoulder is pulled out of socket by trauma. This is particularly common in younger athletes, and usually results in tearing away of the ligaments from the bone. This is called a Bankart lesion.

Patients who are under 25 and sustain a shoulder dislocation with a Bankart lesion, are at a higher risk of recurrence. If they remain active, most of these patients will require shoulder stabilization.

There is controversy as to whether the patient should be treated with stabilization after an initial dislocation. Although this has the advantage of decreasing further damage to the shoulder with repeat dislocations, there is a small group of patients who will be able to do well after the dislocation.

For a patient who needs to be ready for athletic season or who does not want to experience another shoulder dislocation, a primary shoulder repair is a reasonable option. Otherwise, a trial of conservative treatment can be attempted with a short period of immobilization for comfort, followed by a good strengthening program.

If the shoulder remains in place, then no further treatment is required. If a second shoulder dislocation occurs, then I would recommend proceeding with stabilization.

Patients who have had multiple dislocations should consider surgery to prevent further damage to the shoulder joint which may ultimately result in arthritis in the shoulder.

The second type of shoulder instability is due to multidirectional laxity. These are patients who have loose ligaments, and the shoulder gradually stretches out over time. In contrast to patients with unidirectional instability, these patients have instability both anteriorly and posteriorly and inferiorly.

There is often no good history of trauma, and the ligament attachments are usually intact, with the ligament simply being stretched. Also in contrast to a traumatic instability, these are generally treated with conservative measures.

The mainstay of treatment is a good strengthening program and proprioceptive training program for the muscles about the scapula and the rotator cuff. Most patients can be successfully treated with these measures.

In a small group of patients who are unsuccessfully treated with conservative measures, surgical intervention is undertaken. This generally will consist of an arthroscopic anterior-posterior and inferior capsulorrhaphy.

This is an outpatient surgery. The recovery time after surgery is prolonged, and the patient should understand that although they may have a more stable shoulder, the shoulder will be stiff and they will lose some motion. Some patients with multidirectional instability will be unhappy with this.

Ankle Pain

Arthritis is inflammation resulting from the degeneration of cartilage in the joint causing pain, swelling, and stiffness in the joints resulting in restricted movements.

Ankle pain is a common component of ankle arthritis. Arthritis of the foot and ankle joint can occur due to fracture, dislocation, inflammatory disease, or congenital deformity. The foot joints most commonly affected by arthritis are:

  • The joint between the shin bone (tibia) and ankle bone (talus)
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  • The three joints of the foot that include the heel bone, the inner mid-foot bone, and the outer mid-foot bone
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  • The joint of the great toe and foot bone

Types of Arthritis:

Osteoarthritis: Also called degenerative joint disease, this is the most common type of Arthritis, which occurs most often in older people. This disease affects cartilage, the tissue that cushions and protects the ends of bones in a joint.

With osteoarthritis, the cartilage starts to wear away over time. In extreme cases, the cartilage can completely wear away, leaving nothing to protect the bones in a joint, causing bone-on-bone contact. Bones may also bulge, or stick out at the end of a joint, called a bone spur.

Rheumatoid Arthritis: This is an auto-immune disease in which the body’s immune system (the body’s way of fighting infection) attacks healthy joints, tissues, and organs.

It can cause pain, stiffness, swelling, and loss of function in joints. Rheumatoid Arthritis affects mostly joints of the hands and feet and tends to be symmetrical. This means the disease affects the same joints on both sides of the body (both feet) at the same time and with the same symptoms.

Tendonitis refers to inflammation of the tendon. This is often an acute process due to overuse of the tendon. Tendonitis responds well to ice, anti-inflammatories and rest.

Bracing or immobilization may be necessary to allow for complete rest of the tendon. Sometimes a corticosteroid injection, into the tendon sheath or the area around the tendon, may be necessary to provide temporary relief from the pain and inflammation.

It is also important to correct the offending overuse activity that caused the tendonitis in the first place in order to prevent a recurrence. Physical therapy is helpful to control pain and inflammation by using therapeutic modalities. Physical therapy is also helpful to address and correct poor musculoskeletal mechanics which may have contributed to the injury as well.

Post-traumatic arthritis: Arthritis developing following an injury to ankle or foot is called as post-traumatic arthritis. The condition may develop years after the trauma such as a fracture, severe sprain, or ligament tears.

Causes

Rheumatoid arthritis is often caused when the genes responsible for the disease is triggered by infection or any environmental factors. With this trigger body produce antibodies, the defense mechanism of body, against the joint and may cause rheumatoid arthritis.

Fractures at joint surfaces and joint dislocations may predispose an individual to develop post-traumatic arthritis. It is considered that your body secretes certain hormones following injury which may cause death of the cartilage cells.

Uric acid crystal build-up is the cause of gout and long-term crystal build-up in the joints may cause deformity.

Symptoms

Symptoms of foot and ankle arthritis include pain or tenderness, swelling, and stiffness in the joint and limited range of motion.

Diagnosis

The diagnosis of foot and ankle arthritis is made with a medical history, physical examination and X-rays of the affected joint. A bone scan, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans are also performed to diagnose arthritis.

Treatment Options

Nonsurgical treatment options for foot and ankle arthritis include medications (anti-inflammatories), injections (steroids), physical therapy, ankle-foot orthosis (AFO), weight loss, orthotics such as pads or arch supports, and canes or braces to support the joints.

Surgery may be required to treat foot and ankle arthritis, if your symptoms do not get better with conservative treatments. Surgery performed for arthritis of the foot and ankle includes:

Arthroscopic surgery: Arthroscopy is a surgical procedure during which the internal structure of a joint is examined for diagnosis and treatment of problems inside the joint. In arthroscopic examination, a small incision is made in the patient’s skin through which pencil-sized instruments that have a small lens and lighting system (arthroscope) are passed.

Arthroscope magnifies and illuminates the structures of the joint with the light that is transmitted through fiber optics. It is attached to a television camera and the interior of the joint is seen on the television monitor.

Your surgeon can then use probes, forceps, knives, and shavers, to clean the joint area of foreign tissue, inflamed tissue, or bony outgrowths (spurs).

Arthroplasty or Joint Replacement: In this procedure, your surgeon removes the damaged ankle joint and replaces it with an artificial implant. It is usually performed when the joint is severely damaged by osteoarthritis, rheumatoid arthritis or post-traumatic arthritis. Thegoal of ankle replacement is to relieve pain and restore the normal function of the ankle joint.

Arthrodesis: A fusion, also called an arthrodesis involves fusing the bones of the joint together using metal wires or screws.
Your surgeon will discuss the options and help you decide which type of surgery is the most appropriate for you.

Rehabilitation:Following surgery, a rehabilitation program, often involving a physical therapist may help to regain strength and movement. You may need to restrict activities for a minimum of 12 weeks to let the joint reconstruction heal properly. Although recovery is slow, you should be able to resume your normal activities within few months of surgery.

FAST Procedure

The FAST or focused aspiration of scar tissue procedure is a minimally invasive procedure that removes tendon scar tissue from the elbow and allows you to return to your active lifestyle.

Device Description

The FAST procedure uses the TX1 Tissue Removal System which is a portable, self-contained device that offers precise removal of diseased tendon tissue for use in the elbow, knee, ankle, foot and shoulder. The TX1 System removes scar tissue with an ultrasonic aspirator which emulsifies and removes soft tissue.

The TX1 Tissue Removal System is comprised of a console, ultrasonic handpiece, tube set, and foot pedal to control the functions of the system. The TX1 interface has four modes of operation including irrigation, aspiration, debridement, and coagulation. The TX1 consolehasa touch-screen interfacefor selection of settings.

The handpiece kit consists of a TX1 disposable handpiece, tubing, cartridge, single-use antiseptic and applicator, single-use local anesthesia and syringe, 16-guaze dilator, and single use ultrasonic gel.

Procedure

The goal of the FAST procedure is to remove diseased tissue around the affected joint and alleviate the patient’s symptoms.

This procedure takes about 20 minutes and is usually performed under local anesthesia to numb the area. Ultrasound is used to identify the exact area of the joint where scar tissue is causing pain. A small cut of less than 5 mm is made in the skin at the elbow.

After locating the scar tissue, the TX-1 micro tip is inserted into the skin. The computer console delivers ultrasonic energy through the micro tip to break up the scar tissue. A sterile fluid is injected into the area through a saline delivery system housed in the micro tip.

A hollow needle also within the micro tip pulls out the fluid along with the emulsified scar tissue. After the scar tissue is removed, the tiny opening is closed with an adhesive bandage.

Following the procedure you will be allowed to go home.If you experience any discomfort, your doctor will recommend over the counter pain medications. You should avoid any weight-bearing activities for at least 2 weeks after the procedure.

After undergoing FAST procedure, you may be asked to follow certain instructions depending on your condition, type of your work and lifestyle. Most people can returnto work and theactivitiesof daily living without the use of prolonged medications and physical therapy.

Benefits

Benefits of FAST procedure include:

  • Faster recovery
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  • Less pain
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  • Early return to normal activities
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  • Requires less surgical time
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  • Low risk of infection

The FAST procedure is designed to remove the source of pain faster and safer than traditional open surgery. The FAST procedure is an innovative and effective treatment option for patients with tendon related injuries. This new treatment option delivers excellent outcomes and improved quality of life to patients.

Muscle Strains

Muscle strains are more common injuries in sports. Muscle strain refers to an injury of a muscle or its attaching tendons. A tendon is a tough, fibrous cord of tissue that connects muscles to bone.

There are two types of muscle strains, acute strain and chronic strain. Acute strains are caused by excessive stretching or tearing of a ligament. Chronic strains are caused by repetitive movements of muscles and tendons over long periods of time and are more common in tennis players and golfers.

Sports activities such as football, basketball, hockey, gymnastics, boxing, wrestling, tennis, rowing, golf-sports, racquet, throwing, and contact sports place participants at greater risk for strain. The symptoms of a strain are typically pain, swelling, muscle spasm, muscle weakness, inflammation, and cramping.

Back strain occurs when the muscles supporting the spine (back bone) are twisted, pulled or torn. Athletes involving in excessive jumping as in basket ball or volley ball are more susceptible to back strain.

Hamstring muscle strain is a tear in one or more of the muscles at the back of the thigh. It is caused by imbalance between the hamstrings and the muscles in the front of the thigh. Sports that commonly cause a hamstring injury are sprinting sports such as track and field, soccer, and basketball that involve sudden accelerations.

Most sprains and strains will repair themselves with adequate rest, ice application, compression, and elevation. In case of severe injury, a brace or a splint may be used to immobilize the area and to prevent further injury. Surgery is occasionally required to repair the ruptured muscle or torn ligament.

Prevention

The following tips can help reduce the risk of developing muscle strains:

 

  • Sufficient stretching of lower and upper back muscles or warm-up exercises before playing sports is necessary
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  • Follow an exercise program to strengthen the muscles
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  • Eat a healthy well balanced diet that nourishes muscles
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  • Always wear a proper fitting athletic shoe with good support
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  • Use proper equipment suitable for the sport you play
Sprains

Sprain is an injury or tear of the ligament. A ligament is a thick, tough, fibrous tissue that connects bones together.Sprains are common in ankle, spine, knee, thigh, hip, elbow, and wrist joints.

Sprain is caused by trauma, overstretching of the joint during sports activities such as basketball and swimming. Some sports such as gymnastics, basketball, football, hockey, and running cause the ligament tear.

Signs and symptoms include pain and swelling of the affected area, skin discoloration, and joint stiffness.

Treatment Options

Rest: Rest the affected joint as more damage could result from putting pressure on the injured area.

Ice: Application of ice packsto the affected area for 15-20 minutes four times a day for several days will help reduce swelling. Wrap the ice in a towel – never place ice directly over the skin.

Compression: Wrapping the affected joint with an elastic bandage or compression stocking can help to minimize the swelling and support your joint.

Elevation: Elevating the affected joint above heart level will also help reduce swelling and pain.

Your doctor may prescribe nonsteroidal anti-inflammatory drugs to help ease pain and inflammation.

Ulnar Collateral Ligament

The ulnar collateral ligament (UCL), also called medial collateral ligament, is located on the inside of the elbow and connects the ulna bone to the humerus bone.

It is one of the main stabilizing ligaments in the elbow especially with overhead activities such as throwing and pitching. When this ligament is injured or torn, it can end a professional athlete’s career unless surgery is performed.

The common symptoms associated with a UCL tear are as follows:

  • Pain on inner side of the elbow
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  • Unstable elbow joint
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  • Numbness in the little finger or ring finger
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  • Decreased performance in activities such as throwing baseballs or other objects

Ulnar collateral ligament tear is usually caused by repetitive overhead throwing such as in baseball. The stress of repeated throwing on the elbow causes microscopic tissue tears and inflammation.

With continued repetition, eventually the UCL can tear preventing the athlete from throwing with significant speed. If untreated, it can end an athlete’s professional career. UCL tear may also be caused by direct trauma such as with a fall, car accident, or work injury.

Other causes include any activity that requires repetitive overhead motion of the arm such as tennis, pitching sports, fencing, and painting.

UCL tear should be evaluated by an orthopedic specialist for proper diagnosis and treatment. Your physician will perform the following:

  • Medical history
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  • Physical examination including a valgus stress test to assess for elbow instability
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    Other tests such as X-rays and MRI scans may be ordered to confirm the diagnosis.

    Your physician will recommend conservative treatment options to treat the symptoms associated with UCL injury unless you are a professional or collegiate athlete. In these cases, if the patient wants to continue in their sport, surgical reconstruction is performed.

    Conservative treatment options that are commonly recommended for non-athletes include the following:

    • Activity restrictions
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    • Orthotics
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    • Ice compression
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    • Medications
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    • Physical therapy
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    • Pulsed ultrasound to increase blood flow to the injured ligament and promote healing
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    • Professional instruction

    Procedure

    If conservative treatment options fail to resolve the condition and symptoms persist for 6-12 months, your surgeon may recommend ulnar collateral ligament reconstruction surgery.

    UCL reconstruction surgery repairs the UCL by reconstructing it with a tendon from the patient’s own body (autograft) or from a cadaver (allograft). It is also referred to as Tommy John Surgery. The most frequently used tissue is the palmaris longus tendon in the forearm. The basic steps for UCL econstruction surgery include the following:

    • The surgery is performed in an operating room under regional or general anesthesia
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    • Your surgeon will make an incision over the medial epicondyle area
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    • Care is taken to move muscles, tendons, and nerves out of the way
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    • The donor tendon is harvested from either the forearm or below the knee
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    • Your surgeon drills holes into the ulna and humerus bones
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    • Pulsed ultrasound to increase blood flow to the injured ligament and promote healing
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    • The donor tendon is then inserted through the drilled holes in a figure 8 pattern
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    • The tendon is attached to the bone surfaces with special sutures
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    • The incision is closed and covered with sterile dressings

    Finally a splint is applied with the elbow flexed at 90 degrees.

    Post-Operative Care

    After surgery your surgeon will give you guidelines to follow, depending on the type of repair performed and the surgeon’s preference. Common post-operative guidelines include:

    • Elevate your arm above heart level to reduce swelling
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    • Wear an immobilizing splint or cast for 1-3 weeks
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    • Apply ice packs to the surgical area to reduce swelling
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    • Keep the surgical incision clean and dry. Cover the area with plastic wrap when bathing or showering
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    • Physical therapy will be ordered for strengthening and stretching exercises after the removal of the splint or cast
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    • Professional athletes can expect a strenuous strengthening and range of motion rehabilitation program for 6-12 months before returning to their sport
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    • Eating a healthy diet and not smoking will promote healing

    Risks & Complications

    The majority of patients suffer from no complications following UCL Reconstruction surgery; however, complications can occur and include:

     

    • Infection
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    • Limited range of motion
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    • Nerve damage causing numbness, tingling, burning or loss of feeling in the hand and forearm area
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    • Cubital Tunnel Syndrome
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    • Elbow instability
Elbow Pain

The elbow is a hinge joint made up of 3 bones – humerus, radius and ulna. The bones are held together by ligaments to provide stability to the joint. Muscles and tendons move the bones around each other and help in performing various activities. The common causes of elbow pain include:

Elbow Dislocation: Elbow dislocation occurs when the bones that make up the joint are forced out of alignment. Elbow dislocations usually occur when a person falls onto an outstretched hand.

Elbow dislocations can also occur from any traumatic injury such as motor vehicle accidents. When the elbow is dislocated you may have severe pain, swelling, and lack of ability to bend your arm.

Sometimes you cannot feel your hand, or may have no pulse in your wrist because arteries and nerves run along your elbow may be injured.

Elbow Fractures: Fracture is a common injury to the elbow. Elbow fractures may result from a fall onto an outstretched wrist, a direct impact to the elbow or a twisting injury.

Elbow fractures may cause severe pain, swelling, tenderness and painful movements. If a fracture is suspected, immediate intervention by your doctor is necessary. Surgery is often required if a bony displacement is observed.

Golf, a famous sport involves the action of wrist. Insufficient strength in the forearms is the major cause for wrist and hand injuries in golfers. Common injuries in golfers include:

  • Tennis Elbow/Golfer’s Elbow: Tennis elbow is the inflammation of muscles on the outside of the elbow where as tendinitis on the inner side of the elbow is golfer’s elbow. Overuse of the arms or a traumatic blow to the hand may cause tennis elbow or golfer’s elbow.

    These injuries may cause severe pain and tenderness of the affected muscles that radiate down into the forearm, particularly with use of the hand and wrist. Adequate rest and immobility of the affected part helps the muscles to recover and modification of the activities helps in better healing. Heat therapy, followed by a stretching and strengthening exercises and then ice massage may offer be beneficial.

    A tennis elbow strap may relieve the pressure from the muscle attachment. Pain medications may be recommended to relieve the pain and inflammation.

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  • Tendonitis: Tendonitis is inflammation of any of the tendons in the wrist. Tendonitis is usually treated with adequate rest, splinting, ice application, and with non-steroidal anti-inflammatory medicines to reduce the inflammation.
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  • Hook of the hamate fracture: Fracture of the hook of the hamate bone, one of the small bones of the wrist, is another injury common in golfers. The hook of the hamete bone protrudes toward the palm, and is susceptible to injury from the club on a hard hit to the ground as the handle crosses right over the bony hook during gripping the club.

    A splint or cast may be used if the fracture is seen soon after the injury. If there is continued pain, surgery is usually performed to remove the broken bone fragment.

Any problem causing pain, swelling, discoloration, numbness or a tingling sensation, or abnormal position of the hand, wrist, or elbow that persists for more than two or three days should be evaluated by your doctor to establish the cause and obtain the best treatment as early as possible.

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