Suffering with Knee Pain ? A guide to solving your problems

Knee pain is such a common complaint in our Orthopedic practice, that I decided to write something about it; so the readers may benefit by getting an insight into the medical intricacy of diagnosis and treatment planning.

Lets diversify our subjects according to Age. I 'll be focusing on common ailments which cause knee discomfort.

Adults, both Men & Women, between the age group of 25-35 years often complain of Knee pain, with difficulty in getting up from sitting or squatting position, or after climbing stairs. Most such cases are due to Cartilage damage happening at Patello-Femoral interface, commonly called Chondromalacia Patellae or Patellofemoral syndrome. It is relatively more common in young ladies.

Young, active adults are also prone to twisting injuries. Such injuries may cause damage to meniscus and ligaments inside the knee. While a meniscus tear is more likely to cause interference in knee movements, locking episodes, or difficulty in squatting & cross leg sitting; a ligament tear more often causes instability, esp on walking stairs or sloppy, irregular terrain.

In middle age groups between 35-50 years, arthritis becomes a predominant reason for knee pain, with injuries constituting a close second. This is the age of our peak performance years, and we can not allow disability to affect the pace of growth. This is also the the age, when a lot of preventive measures can be undertaken, to prevent or the least delay onset of more severe arthritis. So, I prefer to call it the "Action Age Group"

As we go towards the senior adults in the age group of 50-70 years, Arthritis becomes the predominant reason for knee pain, closely associated with another disorder, Osteoporosis. For optimum bone health, it is important to understand the philosophy behind bone and joint damage,
and take necessary steps to control or cue the problem    www.bonesclinic.com

Slipped Disc, Disc prolapse, Sciatica, Disc Degeneration

Lumbar and Cervical discs are prone to degeneration and prolapse due to their secondary acquired curvatures.
Each disc consists of Outer Annulus, and Inner Nucleus pulposus. As annulus becomes weak, or becomes degenerative, or ruptures secondary to an injury; the nucleus pulposus material extrudes into the spinal canal or the nerve root region. This produces pressure on the nerves producing Sciatica like symptoms.

Technically called a Prolapse Intervertebral disc syndrome; traditionally, it has been labelled as Slipped disc.
A disc protrusion can produce pressure on the spinal cord itself, or on one of the exiting nerve roots producing the typical symptoms.

Treatment of a herniated disc depends on a number of factors including:
•Symptoms experienced by the patient
•Age of the patient
•Activity level of the patient
•Presence of worsening symptoms or neurologic deficit

More than 90 percent patients of new onset Sciatica or disc prolpase, can be satisfactorily treated without surgery. However, there is small chance of recurrence.
Activity and lifestyle modification is important to prevent recurence.

A word of caution to be remembered in such cases: Any patient with neurologic deficit, or worsening pain despite adequate conservative trial, or those presenting with loss of bladder/ bowel control are candidates with significant pressure on the spinal cord or the exiting nerve roots.
Such patients MUST seek Orthopedic opinion, and may require surgical intervention.

Recurrent Dislocation of Patella/ Chronic Patellofemoral Instability

Chronic Patellofemoral instability can be a disabling condition. Female adolescents are the most common first time dislocators. The younger a patient is at the time of first dislocation and the more severe the dislocation, the greater is the risk of subsequent dislocation.
Common causes of Recurrent patellar dislocation are :
1. Increased Q angle
2. Trochlear dysplasia
3. Lax or deficient medial Patellofemoral ligament
4. High riding patella, or small patella
5. Increased knee valgus
6. Hyperextension of the knee

The vastus medialis obliquus and the medial patellofemoral ligament act together as a combined dynamic complex preventing lateral dislocation of patella.

Non-operative measures must be exhausted before offering a surgical option.
Physiotherapy is directed towards closed chain exercises and VMO strengthening, in close supervision of an Orthopedic surgeon.
Surgical options include the soft tissue procedures and bony procedures, depending upon the underlying pathology.
Skeletally immature patients are particularly demanding, as bony procedures should be avoided until maturity.
Soft tissue procedures include the MPFL reconstruction, Medial imbrication, Lateral retinacular release. Bony procedures include Trocheoplasty and Tibial tubercle osteotomy and re-alignment.

Key Points :
1. Outcome with MPFL reconstruction alone in patients with trochlea dysplasia may not be good.
2. There is no evidence that surgical stabilization of the patellofemoral joint decreases long term degenerative changes, despite improving short term stability.

Carpal Tunnel Syndrome CTS

Carpal tunnel syndrome is pressure on the median nerve -- the nerve in the wrist that supplies feeling and movement to parts of the hand. It can lead to numbness, tingling, weakness, or muscle damage in the hand and fingers.
Carpal tunnel syndrome is common in people who perform repetitive motions of the hand and wrist.

A number of medical problems are associated with carpal tunnel syndrome, including:
Bone fractures and arthritis of the wrist, Acromegaly, Diabetes, Alcoholism, Hypothyroidism, Kidney failure and dialysis, Menopause, premenstrual syndrome (PMS), and pregnancy, Obesity, Rheumatoid arthritis, systemic lupus erythematosus (SLE), and scleroderma etc.

Symptoms :
Numbness or tingling in the thumb and next two or three fingers of one or both hands.
Weakness in one or both hands.

Diagnosis may be done by Clinical Evaluation, and Electro-diagnostic tests like Electromyography and Nerve conduction velocity.

Treatment
For patient, who are not responding to conservative management, or when there is documented 
neuronal damage, surgery should be performed.
Carpal tunnel release is a surgical procedure that cuts into the ligament that is pressing on the nerve. Surgery is successful most of the time, but recovery depends on how long the nerve compression has been occurring and its severity.

The procedure can be done under local anesthesia. The procedure involves a skin incision of approximately 1 inch, which heals in a week. The patient is discharged on the day of surgery, and can start normal activities in a week.

Shoulder Dislocations

Shoulder dislocations commonly seen in young individuals occur as a result of direct or indirect impact over the shoulder joint. There are two broad types of dislocations described; based on the position of the Humeral head.
Anterior dislocations are more common. Posterior dislocation are a rare entity; often seen in epileptics. After an impact, the patient feels sudden give way in the shoulder joint followed by inability to move the upper limb. This is associated with pain which becomes worse with attempted movements.
The common scenario is a patient supporting his affected upper limb by the other hand.
Early of a shoulder dislocation is of paramount importance. If a shoulder dislocation is neglected, it may lose its vascularity and become necrotic.
Careful clinical assessment is required to confirm the type of dislocation.
The mechanism of reduction is to reverse the order of the deforming force.
In 90 percent of cases, a shoulder dislocation may be reduced without requiring any form of anesthesia. In some cases, a mild sedative helps reduce the patient's apprehension. Rarely an open reduction is required and particularly in patients presenting late to the clinic.
Patient's co-operation is of utmost importance.
Every shoulder dislocation has a risk of re-dislocation with similar or less severe impact. This happens due to laxity of tissue surrounding the shoulder joint.
After a dislocation has been reduced, the patient must be forewarned about this complication.
The risk of re-dislocation may be substantially reduced with supervised physiotherapy and avoidance of the precipitating forces.
In a fresh dislocation occurring in a young patient; after performing a closed reduction, the shoulder joint should be splinted for a period of 2-3 weeks. In elderly patients, early passive exercises are allowed for fear of causing stiffness of immobilization.
A patient with history of shoulder dislocation should be kept under close observation.
If there are lesions in the glenoid labrum (bankart's lesions) or the Humeral head (Hill Sach's and Reverse Hill Sach's lesions), sometimes an operative intervention may be required in patients presenting with recurrent dislocations or shoulder instability that interferes with daily routine activities.
The risk of dislocation reduces with increasing age.

In Toe Gait in Children

Intoeing means that when a child walks or runs, the feet turn inward instead of pointing straight ahead. It is commonly referred to as being "pigeon-toed."

Intoeing is often first noticed by parents when a baby begins walking. In the vast majority of children younger than 8 years old, intoeing will almost always correct itself without the use of casts, braces, surgery, or any special treatment. A child whose intoeing is associated with pain, swelling, or a limp should be evaluated by an orthopaedic surgeon.

There are three common conditions causing intoeing:

•Curved foot (metatarsus adductus)
•Twisted shin (tibia torsion)
•Twisted thighbone (femoral anteversion)

Metatarsus adductus improves by itself most of the time, usually over the first 4 to 6 months of life. Babies aged 6 to 9 months with severe deformity or feet that are very rigid may be treated with casts or special shoes with a high rate of success. Surgery to straighten the foot is seldom required.

Tibial torsion almost always improves without treatment, and usually before school age. Splints, special shoes, and exercise programs do not help. Surgery to re-set the bone may be done in a child who is at least 8 to10 years old and has a severe twist that causes significant walking problems.

Femoral anteversion spontaneously corrects in almost all children as they grow older. Studies have found that special shoes, braces, and exercises do not help. Surgery is usually not considered unless the child is older than 9 or 10 years and has a severe deformity that causes tripping and an unsightly gait. Like surgery for tibial torsion, during the procedure for femoral anteversion, the femur is cut and rotated back into proper alignment.

Treatment is mostly Reassurance and Observation
Ref:  http://orthoinfo.aaos.org/topic.cfm?topic=a00055

Pulled Elbow or Nursemaid's Elbow

Nursemaid elbow or Pulled Elbow, as is commonly called, most commonly occurs in children aged 1-4 years. The usual history is a child been lifted or pulled by the wrist, followed by pain and loss of active forearm rotation.

The forearm is usually flexed 15-20 degrees at the elbow, and the forearm is partially pronated. Often, the weight of the affected arm is supported with the other hand. The patient resists supination/pronation as well as flexion/extension of the forearm.

Axial traction is the most common cause of nursemaid elbow.

Ultrasonography has been used as a noninvasive modality to assess for annular ligamentous injury and displacement of the radial head from the capitellum. It has also been used to assess progress of treatment for patients with recurrent subluxations.

Once diagnosed, the radial head can be easily relocated using simple manoeuvres. The patient should be able to completely supinate the forearm, after a successful reduction.

Age younger than 2 years and a delay of more than 4 hours before treatment have been associated with failure to use an affected arm within 30 minutes. An important part of the management is educating parents about the risk of reoccurrence.

Coccidynia

Coccidynia is classically defined as pain in the coccyx region. It may occur secondary to a fracture in coccyx or a ligamentous sprain in sacrococcygeal ligament. Patients usually complaint of pain while sitting on hard surface, or during defecation.
Treatment is mainly supportive.
Most patients respond to Ultrasonic and IFT stimulation therapy. In resistant cases, local steroid injection along with local anaesthetic may be given.
Surgical option is considered, in rare circumstances.

Chondromalacia Patellae or Patellofemoral Syndrome

Dr Anurag Awasthi, Orthopaedic Specialist, Sohna Road, Gurgaon; 9718112112

Chondromalacia of the patella occurs in adolescents and young adults. This condition is more common in females. It can be related to the abnormal position of the knee.

Chondromalacia patella is abnormal softening of the cartilage of the under the kneecap (patella). Chondromalacia patella is the most common cause of chronic knee pain. Chondromalacia patella results from degeneration of cartilage due to poor alignment of the kneecap as it slides over the lower end of the thigh bone (femur). This process is, therefore, sometimes referred to as patellofemoral syndrome.

Selective strengthening of the inner portion of the quadriceps muscle will help normalize the tracking of the patella.

If patient's symptoms do not improve with conservative therapy, arthroscopy of the knee may be performed to look for possible lesions, and treatment.

Osgood Schlatter Disease of the Adolescent knee

Osgood Schlatter disease is the osteochondritis of the tibial tuberosity occurring in adolescent knees.
It causes pain and mild swelling just below the knee joint over the prominence in the front of the upper leg.
Patients complain of difficulty in running activities.
It is a developmental affection of the tibial tuberosity apophysis, and settles with completion of growth maturity, and fusion of the apophysis.
In severe case, patients may be offered splintage in the form of brace or plaster cast.
For those not responding to conservative trials, needling of the lesion triggers the cure.

Shoulder Injuries and Disorders- Frozen Shoulder

Frozen shoulder or the technical name Adhesive Capsulitis of Shoulder, mostly seen in middle aged women and diabetics, causes global loss of shoulder movements in all directions.
Usually a self limiting disease, but the prolonged disease course causes much disability.
Early cases should be managed by a course of physiotherapy.
In non- responding patients, manipulation under anesthesia after injecting and inflating the shoulder joint capsule with saline is an alternative.
Prolonged supervised physiotherapy is almost always necessary.

Shoulder Injuries and Disorders- Impingement Syndrome

Shoulder impingement syndrome causes limitation of shoulder movements in one or more directions, but never complete global loss of movements.
Also known as a "Painful arc syndrome"; when the arm is taken overhead in the window cleaning position, patient catches pain. Pain is reproduced on every attempt to do this manoeuvre.
The patholy lies in the reduction of space for the free excursion of the rotator cuff tendons mainly Supraspinatus, beneath the acromion process.
This may occur due to inflammation of tendon itself, due to thickening of acromion process of shoulder blade (scapula); or due to repetitive stress injuries of the rotator cuff.
Treatment of this disorder is mostly conservative.
Most patients respond to suitable modification of activity or local steroid infiltration.
In patients who are resistant to conservative trials, decompression of the sub-acromial space may be performed surgically (Acromioplasty).

Shoulder Injuries & Disorders : Acromioclavicular Joint Injuries

AC Joint injuries are common due to fall on out-stretched hand. They have significant impact in overhead activities and sports.
Patients with AC joint injuries have been classified into six types, with severity ranging from simple sprain to complete destruction of all supporting ligaments and marked displacement of the collar bone from its normal position.
Not all patients with AC joint injury need surgery.
Most patients wherein the AC joint remains even in partial contact may be managed by a sling support. For more severe injuries, a reconstruction of ligaments may be taken immediately after the injury or at a later date.

Collar Bone fracture : Is operation necessary ??

Collar bone (Clavicle) fracture occurs commonly due to indirect forces with fall on the out-stretched hand.
Most comon area of fractur is at the junction of inner 2/3 and outer 1/3. However, at times, the fracture occurs more outwards and closer to the shoulder joint. The latter presents a technically challenging scenario.

Most collar bone fractures can be treated without surgery. Usually a cuff and collar sing is provided for pain relief, and exercises are started after 4 weeks.
In certain situations, wherein the vascular or neural structures are in jeopardy due to pressure by fracture fragments, operation may be required. Surgery is also indicated in fractures occurring close to the shoulder joint.

With greater emphasis on cosmetic appearance, surgery is often demanded by young girls, who do not want a fracture bump. In such cases, a plate may be used with minimum surgical scar.

Non discogenic Backache : Facet joint Arthropathy

Most Sciatica is labelled to be because of a protruding disc (disc prolapse). However, there are other reasons to it. Making a correct diagnosis, is therefore important to correctly relieve the symptoms.
Pain due to disc disease are usually aggravated with forward bending; however, pain of facetal arthropathy is worsened by backward bending.
In case of Facetal Arthropathy, the facet joints become more blurred on the MRI images, with some enlargement and irregularity of the surrounding bones.
The treatment varies from supervised physiotherapy, to local injections to fusion surgery.
Physiotherapy focusses on building the tone of abdominal and back muscles, and general postural training.
Injection therapy includes local steroid infiltration in the facet joints; this procedure is performed with the help of portable xray control images. It offers rlief in 60-80 percent of patients.
The last resort to a troublesome facetal arthropathy is fusion surgery.

Gout and Pseudogout: Arthritis of crystal deposition

Gout is characterized by excessive uric acid levels in blood and deposition of sodium monourate crystals in the joint and subcutaneous tissues (tophi). The deposition of urate crystals and reaction with the white blood cells (phagocytes) incites the release of inflammatory mediators, which cause the characteristic pain and inflammation.

During an acute attack, the involved joint is red, inflamed and tender. The site of predilection is the 1st Meta-tarso-phalangeal joint of the great toe. However, in late stages other joints may be affected, particularly knee and ankle. Besides, there may be tophi deposition around elbow, or toes.

Treatment of an acute attack is primarily NSAIDs like Ibuprofen, Naproxen etc. Corticosteroids may be used orally or injected into the inflamed joint, provided there are no signs of infection. Another drug used to control acute attacks is Colchicine; use limited due to incidence of diarrhoea. For chronic attacks, the frequency may be reduced using Colchicine or other drugs like Probenecid and Allopurinol.

Another condition that sometimes mimics Gout, is Pseudogout.
The latter is characterized by deposition of CPPD crystals in the joints; and primarily involves the knee.

Ankylosing Spondylitis- Disease of the Young

Ankylosing spondylitis  or AS, is a form of arthritis that primarily affects the Sacroiliac joints and the spine, although other joints may become involved at advanced stages.
Progreesive stiffness and ossification of ligaments produces the characteristic forward stooped posture.AS can also cause inflammation, pain and stiffness in other areas of the body such as the  hip joints, ribs, heels etc. Sometimes the eyes may become involved (known as Iritis or Uveitis). 
Most patients complain of early morning stiffness that typically lasts for 30 minutes to 2 hours; improvement occurs with activity and stretching. AS is clinically characterized by exacerbations and remissions. Patient may remain symptom free for a long duration before the recurrence of symptoms. AS can be very debilitating, and in some cases, lead to disability.
Patients with positive HLA B-27 factor and a positive family history are at risk.
Treatment of AS depends upon the severity of symptoms. Patients with early and mild symptoms are best managed by supervised physiotherapy and stretching programmes.
Medications that reduce pain include NSAIDs ( Indomethacin, Naproxen ). TNF-blocking medications (Etanercept , Infliximab , Adalimumab ),  have been shown to be extremely effective for treating ankylosing spondylitis by stopping disease activity, decreasing inflammation, and improving spinal mobility.
Surgical treatment for AS is required in patients with severe Kyphosis (excessive dorsal curvature of spine), limitation of neck movement, or with ankylosed hips. 
Pedicle subtraction osteotomy may be performed at the spine to improve posture.


http://www.medicinenet.com/ankylosing_spondylitis/article.htm 

Ganglion Cysts

Ganglion cysts appear to arise often on the extensor aspect of the wrist and hand. They may be associated with the degenerative conditions of the joints. They may occur adjacent to joints, tendons, fascial planes, and within bone.

Usually soft in consistency, they may be firm to hard at times. These cysts are filled with gelatinous substance, which can be removed by a thick needle aspiration.The aspiration may be followed by steroid injection, or sometime hylase injection.

Surgery is required in recurrent cases, and it is important to excise the tail of the cyst up to the joint from which it seems to arise.


http://www.bonetumor.org/tumors-foot-and-ankle/ganglion-cyst-foot-and-ankle

Chronic Pain and Depression

Chronic musculo-skeletal pain syndromes are often associated with variable amount of depressive illnesses. Treatment of such patients purely by using analgesics often proves futile. A comprehensive approach with involvement of psychotherapist is often mandatory.

In a recent report, US-FDA had approved the use of Duloxetine hydrochloride for use in conjunction with nos-steroidal and opioid analgesics.
The molecule has been is use in India for some time now, and has given improved results when used together with analgesics.

Advanced Hip Arthritis

Pain in the hip joints with progressive limitation of activity is the predominant symptom in a case of advanced Hip arthritis. It may be a result of degenerative changes,/ inflammatory arthritis (RA),/ post-traumatic,/ Post AVN Hip etc.
The picture shows almost complete obliteration of both hip joint spaces (more on the right side).
This patient had a reasonable range of motion in left hip, so we decided to go for conservative management.

The right hip was much worse.
We discussed the options with the patient. The choice of surgery in this case is a Total Hip Replacement (THR). The various bearing options are- Metal on metal/ Ceramic on ceramic/ metal on UHMWPE/ ceramic on UHMWPE.
The choice of bearing depends upon patient factors and age.
Pl read the blog on bearing options regarding further details.