Onycholysis

What is Onycholysis?

Onycholysis is the separation of a fingernail or toenail from its pink nail bed. The separation occurs gradually and is painless.

The most common cause of onycholysis is trauma. Even slight trauma can cause onycholysis when it happens repetitively — for example, the daily tapping of long fingernails on a keyboard or counter. Onycholysis also can be caused by manicure tools that are pushed beneath the nail to clear dirt or smooth the nail. Too much moisture also can cause the problem.

Some medical conditions can cause onycholysis, generally by changing the nail’s shape or the contour of the soft tissue bed beneath it. In these situations, the nail cannot attach smoothly to the nail bed.

  • Fungal infections of the nails thicken the tissue immediately underneath the nail plate and cause edge of the nail to lift.
  • The skin condition psoriasis is a common cause of onycholysis.
  • After exposure to some medicines the nail can react to sun exposure by lifting away from its bed.
  • An overactive thyroid gland can cause onycholysis.

Symptoms of Onycholysis?

A nail that has lifted from its bed at its end can have an irregular border between the pink portion of the nail and the white outside edge of the nail. A greater portion of the nail is opaque, either whitened or discolored to yellow or green. Depending on the cause of onycholysis, the nail may have collected thickened skin underneath the edge of its nail plate, and the nail plate may have a deformed shape with pits or indentations in the nail surface, a bent nail edge or coarse thickening of the nail.

Diagnosis of Onycholysis?

Your doctor will be able to confirm that you have onycholysis by examining your fingernails or toenails. If the cause of onycholysis is not obvious, your doctor will note additional characteristics of your nails, such as their shape and color, the presence of indentations in the nail surface, and the appearance of the skin under and around the nail. He or she also will examine you to check for evidence of skin rashes or thyroid problems.

If your doctor suspects that a fungal infection is the cause of nail changes, he or she might scrape a sample of tissue from beneath the nail plate. This sample can be tested in a laboratory to check for fungus.

Expected Duration:

Nails are slow to grow and take time to repair themselves. The portion of nail that has separated from the skin surface beneath it will not reattach. Onycholysis only goes away after new nail has replaced the affected area. It takes four to six months for a fingernail to fully regrow, and twice as long for toenails. Some nail problems are difficult to cure and may affect the nail appearance permanently.

Prevention of Onycholysis:

Some preventive measures will make onycholysis less likely to occur:

  • Cut nails to a comfortable length so that they will be less likely to endure repeated trauma from tapping in everyday use.
  • Wear rubber gloves to avoid repetitive immersion in water. Nails expand after they are exposed to moisture and then shrink while drying, a cycle that over time can make them brittle. Keeping your nails dry also will help prevent fungal infections.
  • Avoid frequent exposure to harsh chemicals, such as nail polish remover.

Treatment of Onycholysis:

Because the portion of nail that has lifted away from its bed may catch on edges when you move abruptly, it is a good idea to trim the nail close to the place where it separates from the nail bed. A physician can help you do this.

Treatment for onycholysis depends on the cause of the problem:

  • Treatment for hyperthyroidism can permit the nails to regrow normally.
  • Some treatments for psoriasis that are given by mouth may improve nail health.
  • Fungal nail infections sometimes can be treated with prescription medicines. However, the medicines required to treat the nail condition are expensive and can have side effects. You should discuss the pros and cons of treatment with your doctor.

Plantar Warts

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Plantar warts are hard, grainy growths that usually appear on the heels or balls of your feet, areas that feel the most pressure. This pressure also may cause plantar warts to grow inward beneath a hard, thick layer of skin (callus).

Plantar warts are caused by the human papillomavirus (HPV). The virus enters your body through tiny cuts, breaks or other weak spots on the bottom of your feet.

Most plantar warts aren’t a serious health concern and may not require treatment. But plantar warts can cause discomfort or pain. If self-care treatments for plantar warts don’t work, you may want to see your doctor to have them removed.

Symptoms of Plantar Warts

Plantar wart signs and symptoms include:

  • A small, fleshy, rough, grainy growth (lesion) on the bottom of your foot
  • Hard, thickened skin (callus) over a well-defined “spot” on the skin, where a wart has grown inward
  • Black pinpoints, which are commonly called wart seeds but are actually small, clotted blood vessels
  • A lesion that interrupts the normal lines and ridges in the skin of your foot
  • Pain or tenderness when walking or standing

Causes of Plantar Warts

Plantar warts are caused by an infection with the human papillomavirus (HPV) in the outer layer of skin on the soles of your feet.

More than 100 types of HPV exist, but only a few cause warts on your feet. Other types of HPV are more likely to cause warts on other areas of your skin or on mucous membranes.

Transmission of the virus
Each person’s immune system responds differently to HPV. Not everyone who comes in contact with it develops warts. Even people in the same family react to the virus differently.

The HPV strains that cause plantar warts aren’t highly contagious. So the virus isn’t easily transmitted by direct contact from one person to another. But it thrives in warm, moist environments. Consequently, you may contract the virus by walking barefoot around swimming pools or locker rooms. If the virus spreads from the first site of infection, more warts may appear.

The virus also needs to have a point of entry into the skin of the foot:

  • Cracks in dry skin
  • Cuts or scrapes
  • Wet, softened, fragile skin from being in the water a long time

Complications

When plantar warts cause pain, you may alter your normal posture or gait perhaps without realizing it. Eventually, this change in how you stand, walk or run can cause muscle or joint discomfort.

Treatments and Drugs

Most plantar warts go away without treatment, though it may take a year or two. If your warts are painful or spreading, you may want to try treating them with over-the-counter (nonprescription) medications or home remedies. You may need many repeated treatments before the warts go away, and they may return later.

If your self-care approaches haven’t helped, talk with your doctor about trying these treatments:

  • Stronger peeling medicine (salicylic acid). Prescription-strength wart medications with salicylic acid work by removing layers of a wart a little bit at a time. They may also stimulate your immune system’s ability to fight the wart.Your doctor will likely suggest you apply the medicine regularly at home, followed by occasional visits to the doctor’s office. Your doctor may pare away part of the wart or use freezing treatment (cryotherapy). Studies show that salicylic acid is more effective when combined with freezing.
  • Freezing medicine (cryotherapy). Freezing therapy done at a doctor’s office involves applying liquid nitrogen to your wart, either with a spray or a cotton swab. Your doctor may numb the area first because it can be painful when the liquid nitrogen is applied.The chemical causes a blister to form around your wart, and the dead tissue sloughs off within a week or so. It may also stimulate your immune system to fight viral warts. Usually, you’ll return to the doctor’s office for repeat treatments every three to four weeks until the wart disappears.

    Some studies show that this treatment is more effective when combined with salicylic acid treatments.

Surgical or other procedures

If salicylic acid and freezing don’t work, our doctor may recommend one or more of the following treatments:

  • Warts Removal. Our doctor cuts away the wart or destroys it by using an electric needle (electrodesiccation and curettage). This procedure can be painful, so our doctor will numb your skin first.
  • Laser treatment. Pulsed-dye laser treatment burns closed (cauterizes) tiny blood vessels. The infected tissue eventually dies, and the wart falls off. The evidence for the effectiveness of this method is limited, and it can cause pain and scarring.

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Morton’s Neuroma

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Morton’s neuroma is a painful condition that affects the ball of your foot, most commonly the area between your third and fourth toes. Morton’s neuroma may feel as if you are standing on a pebble in your shoe or on a fold in your sock.

Morton’s neuroma involves a thickening of the tissue around one of the nerves leading to your toes. This can cause a sharp, burning pain in the ball of your foot. Your toes also may sting, burn or feel numb.

High-heeled shoes have been linked to the development of Morton’s neuroma. Many people experience relief by switching to lower heeled shoes with wider toe boxes. Sometimes corticosteroid injections or surgery may be necessary.

Symptoms of Morton’s Neuroma

Typically, there’s no outward sign of this condition, such as a lump. Instead, you may experience the following symptoms:

  • A feeling as if you’re standing on a pebble in your shoe
  • A burning pain in the ball of your foot that may radiate into your toes
  • Tingling or numbness in your toes

Causes of Morton’s Neuroma

Morton’s neuroma seems to occur in response to irritation, pressure or injury to one of the nerves that lead to your toes.

Risks Factors of Morton’s Neuroma

Factors that appear to contribute to Morton’s neuroma include:

  • High heels. Wearing high-heeled shoes or shoes that are tight or ill fitting can place extra pressure on your toes and the ball of your foot.
  • Certain sports. Participating in high-impact athletic activities such as jogging or running may subject your feet to repetitive trauma. Sports that feature tight shoes, such as snow skiing or rock climbing, can put pressure on your toes.
  • Foot deformities. People who have bunions, hammertoes, high arches or flatfeet are at higher risk of developing Morton’s neuroma.

Diagnosis of Morton’s Neuroma

During the exam, your doctor will press on your foot to feel for a mass or tender spot. There may also be a feeling of “clicking” between the bones of your foot.

Imaging tests
Some imaging tests are more useful than others in the diagnosis of Morton’s neuroma:

  • X-rays. Your doctor is likely to order X-rays of your foot, to rule out other causes of your pain — such as a stress fracture.
  • Ultrasound. This technology uses sound waves to create real-time images of internal structures. Ultrasound is particularly good at revealing soft tissue abnormalities, such as neuromas.
  • Magnetic resonance imaging (MRI). Using radio waves and a strong magnetic field, an MRI also is good at visualizing soft tissues. But it’s an expensive test and often indicates neuromas in people who have no symptoms.

Treatment of Morton’s Neuroma

Treatment depends on the severity of your symptoms. Your doctor will likely recommend trying conservative approaches first.

Therapy
Arch supports and foot pads fit inside your shoe and help reduce pressure on the nerve. These can be purchased over-the-counter, or your doctor may prescribe a custom-made, individually designed shoe insert — molded to fit the exact contours of your foot.

Surgical and other procedures
If conservative treatments haven’t helped, your doctor might suggest:

  • Injections. Some people are helped by the injection of steroids into the painful area.
  • Decompression surgery. In some cases, surgeons can relieve the pressure on the nerve by cutting nearby structures, such as the ligament that binds together some of the bones in the front of the foot.
  • Removal of the nerve. Surgical removal of the growth may be necessary if other treatments fail to provide pain relief. Although surgery is usually successful, the procedure can result in permanent numbness in the affected toes.

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Bunion

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A bunion is a bony bump that forms on the joint at the base of your big toe. A bunion forms when your big toe pushes against your next toe, forcing the joint of your big toe to get bigger and stick out. The skin over the bunion might be red and sore.

Wearing tight, narrow shoes might cause bunions or might make them worse. Bunions can also develop as a result of an inherited structural defect, stress on your foot or a medical condition, such as arthritis.

Smaller bunions (bunionettes) also can develop on the joint of your little toes.

Symptoms of Bunion

The signs and symptoms of a bunion include:

  • A bulging bump on the outside of the base of your big toe
  • Swelling, redness or soreness around your big toe joint
  • Thickening of the skin at the base of your big toe
  • Corns or calluses — these often develop where the first and second toes overlap
  • Persistent or intermittent pain
  • Restricted movement of your big toe

When to see a Doctor

Although bunions often require no medical treatment, see your doctor or a doctor who specializes in treating foot disorders (podiatrist or orthopedic foot specialist) if you have:

  • Persistent big toe or foot pain
  • A visible bump on your big toe joint
  • Decreased movement of your big toe or foot
  • Difficulty finding shoes that fit properly because of a bunion

Causes of Bunion

Bunions develop when the pressures of bearing and shifting your weight fall unevenly on the joints and tendons in your feet. This imbalance in pressure makes your big toe joint unstable, eventually molding the parts of the joint into a hard knob that juts out beyond the normal shape of your foot.

Experts disagree on whether tight, high-heeled or too-narrow shoes cause bunions or whether footwear simply contributes to bunion development. Other causes include:

  • Inherited foot type
  • Foot injuries
  • Deformities present at birth (congenital)

Bunions may be associated with certain types of arthritis, particularly inflammatory types, such as rheumatoid arthritis. An occupation that puts extra stress on your feet or one that requires you to wear pointed shoes also can be a cause.

Risk Factors of Bunion

These factors may increase your risk of bunions:

  • High heels. Wearing high heels forces your toes into the front of your shoes, often crowding your toes.
  • Ill-fitting shoes. People who wear shoes that are too tight, too narrow or too pointed are more susceptible to bunions.
  • Arthritis. Pain from arthritis may change the way you walk, making you more susceptible to bunions.
  • Heredity. The tendency to develop bunions may be present because of an inherited structural foot defect.

Complications of Bunion

Although they don’t always cause problems, bunions are permanent unless surgically corrected. Possible complications include:

  • Bursitis. This painful condition occurs when the small fluid-filled pads (bursae) that cushion bones, tendons and muscles near your joints become inflamed.
  • Hammertoe. An abnormal bend that occurs in the middle joint of a toe, usually the toe next to your big toe, can cause pain and pressure.
  • Metatarsalgia. This condition causes pain and inflammation in the ball of your foot.

Treatments of Bunion

Treatment options vary depending on the severity of your bunion and the amount of pain it causes.

Conservative treatment
Nonsurgical treatments that may relieve the pain and pressure of a bunion include:

  • Changing shoes. Wear roomy, comfortable shoes that provide plenty of space for your toes.
  • Padding and taping or splinting. Your doctor can help you tape and pad your foot in a normal position. This can reduce stress on the bunion and alleviate your pain.
  • Medications.
  • Shoe inserts. Padded shoe inserts can help distribute pressure evenly when you move your feet, reducing your symptoms and preventing your bunion from getting worse. Over-the-counter arch supports can provide relief for some people, although others may require prescription orthotic devices.
  • Applying ice. Icing your bunion after you’ve been on your feet too long can help relieve soreness and inflammation.

Surgical options
If conservative treatment doesn’t provide relief from your symptoms, you may need surgery. The goal of bunion surgery is to relieve discomfort by returning your toe to the correct position.

There are a number of surgical procedures for bunions, and no one technique is best for every problem.

Surgical procedures for bunions might involve:

  • Removing the swollen tissue from around your big toe joint
  • Straightening your big toe by removing part of the bone
  • Realigning the long bone between the back part of your foot and your big toe, to straighten out the abnormal angle in your big toe joint
  • Joining the bones of your affected joint permanently

It’s possible you may be able to walk on your foot immediately after a bunion procedure. However, full recovery can take weeks to months. To prevent a recurrence, you’ll need to wear proper shoes after recovery. It’s unlikely that you’ll be able to wear narrower shoes after surgery.

Surgery isn’t recommended unless a bunion causes you frequent pain or interferes with your daily activities. Talk to your doctor about what you can expect after bunion surgery.

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Haglund’s Deformity

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Haglund’s deformity is a bony enlargement on the back of the heel that most often leads to painful bursitis, which is an inflammation of the bursa (a fluid-filled sac between the tendon and bone). In Haglund’s deformity, the soft tissue near the Achilles tendon becomes irritated when the bony enlargement rubs against shoes.

Haglund’s deformity is often called “pump bump” because the rigid backs of pump-style shoes can create pressure that aggravates the enlargement when walking.

Symptoms of Haglund’s Deformity

Haglund’s deformity can occur in one or both feet. The signs and symptoms include:

  • A noticeable bump on the back of heel.
  • Pain in the area where the Achilles tendon attaches to the heel.
  • Swelling in the back of the heel.
  • Redness near the inflamed tissue.

Causes of Haglund’s Deformity

To some extent, heredity plays a role in Haglund’s deformity. People can inherit a type of foot structure that makes them prone to developing this condition.

For example, high arches can contribute to Haglund’s deformity. The Achilles tendon attaches to the back of the heel bone, and in a person with high arches, the heel bone is tilted backward into the Achilles tendon. This causes the uppermost portion of the back of the heel bone to rub against the tendon. Eventually, due to this constant irritation, a bony protrusion develops and the bursa becomes inflamed. It is the inflamed bursa that produces the redness and swelling associated with Haglund’s deformity.

A tight Achilles tendon can also play a role in Haglund’s deformity, causing pain by compressing the tender and inflamed bursa. In contrast, a tendon that is more flexible results in less pressure against the painful bursa.

Another possible contributor to Haglund’s deformity is a tendency to walk on the outside of the heel. This tendency, which produces wear on the outer edge of the sole of the shoe, causes the heel to rotate inward, resulting in a grinding of the heel bone against the tendon. The tendon protects itself by forming a bursa, which eventually becomes inflamed and tender.

Diagnosis of Haglund’s Deformity

After evaluating the patient’s symptoms, the foot and ankle surgeon will examine the foot. In addition, x-rays will be requested to help the surgeon evaluate the structure of the heel bone.

Treatment of Haglund’s Deformity

Non-surgical treatment of Haglund’s deformity is aimed at reducing the inflammation of the bursa. While these approaches can resolve the bursitis, they will not shrink the bony protrusion. Non-surgical treatment can include one or more of the following:

  • Removal of the problem: Walking without shoes takes the pressure completely off the affected area.
  • Medication. Anti-inflammatory medications may help reduce the pain and inflammation. Some patients also find that a topical pain reliever, which is applied directly to the inflamed area, is beneficial.
  • Ice. To reduce swelling, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
  • Exercises. Stretching exercises help relieve tension from the Achilles tendon. These exercises are especially important for the patient who has a tight heel cord.
  • Heel lifts. Patients with high arches may find that heel lifts placed inside the shoe decrease the pressure on the heel.
  • Heel pads. Placing pads inside the shoe cushions the heel and may help reduce irritation when walking.
  • Shoe modification. Wearing shoes that are backless or have soft backs will avoid or minimize irritation.
  • Physical therapy. A physical therapist can help identify biomechanical abnormalities that may be contributing to inflammation and recommend appropriate strengthening and stretching exercises to help decrease discomfort and prevent the need for surgery.
  • Orthotic devices. These custom arch supports are helpful because they control the motion in the foot, which can aggravate symptoms.
  • Immobilization. In some cases, casting may be necessary to reduce symptoms.

If non-surgical treatment fails to provide adequate pain relief, surgery may be needed. surgical treatment: Debridement of affected tendon and excision of retrocalcaneal bursa and haglund deformity. A central approach facilitates such debridement but necessitates detachment of 50% of the tendo achilies from calcaneus which is usually sutered back using bone anchors. In severe cases after debridement of substantial portion of the tendo achilies, augmentation may be done with the transfer of the flexor hallusis longus muscle.

Prevention of Haglund’s Deformity

A recurrence of Haglund’s deformity may be prevented by:

  • Wearing appropriate shoes; avoid pumps and high-heeled shoes.
  • Using arch supports or orthotic devices.
  • Performing stretching exercises to prevent the Achilles tendon from tightening.
  • Avoiding running on hard surfaces and running uphill.

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Ankle Sprain

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What is Ankle Sprain?

An ankle sprain refers to tearing of the ligaments of the ankle. The most common ankle sprain occurs on the lateral or outside part of the ankle. This is an extremely common injury which affects many people during a wide variety of activities. It can happen in the setting of an ankle fracture (i.e. when the bones of the ankle also break). Most commonly, however, it occurs in isolation.

 

What are the symptoms of Ankle Sprain?

Patients report pain after having twisted an ankle. This usually occurs due to an inversion injury, which means the foot rolls underneath the ankle or leg. It commonly occurs during sports. Patients will complain of pain on the outside of their ankle and various degrees of swelling and bleeding under the skin (i.e. bruising). Technically, this bruising is referred to as ecchymosis. Depending on the severity of the sprain, a person may or may not be able to put weight on the foot.

What are the risk factors for Ankle Sprain?
As noted above, these injuries occur when the ankle is twisted underneath the leg, called inversion. Risk factors are those activities, such as basketball and jumping sports, in which an athlete can come down on and turn the ankle or step on an opponent’s foot.

Some people are predisposed to ankle sprains. In people with a hindfoot varus, which means that the general nature or posture of the heels is slightly turned toward the inside, these injuries are more common. This is because it is easier to turn on the ankle.

In those who have had a severe sprain in the past, it is also easier to turn the ankle and cause a new sprain. Therefore, one of the risk factors of spraining the ankle is having instability. Those who have weak muscles, especially those called the peroneals which run along the outside of the ankle, may be more predisposed.

The anatomy of Ankle Ligaments:

There are multiple ligaments in the ankle. Ligaments in general are those structures that connect bone-to-bone. Tendons, on the other hand, connect muscle-to-bone and allow those muscles to exert their force. In the case of an ankle sprain, there are several commonly sprained ligaments. The two most important are the following:

1.The ATFL or anterior talofibular ligament, which connects the talus to the fibula on the outside of the ankle.
2.The CFL or calcaneal fibular ligament, which connects the fibula to the calcaneus below.
3. Finally, there is a third ligament which is not as commonly torn. It runs more in the back of the ankle and is called the PTFL or posterior talofibular ligament. These must be differentiated from the so-called high ankle sprain ligaments, which are completely different and located higher up the leg.

How is an Ankle Sprain Diagnosed?
Ankle sprains can be diagnosed fairly easily given that they are common injuries. The location of pain on the outside of the ankle with tenderness and swelling in a patient who has an ankle with inversion is very suggestive. In these patients, normal X-rays also suggest that the bone has not been broken and instead the ankle ligaments have been torn or sprained.

It is very important, however, not to simply regard any injury as an ankle sprain because other injuries can occur as well. For example, the peroneal tendons mentioned above can be torn. There can also be fractures in other bones around the ankle including the fifth metatarsal and the anterior process of the calcaneus. In very severe cases, an MRI may be warranted to rule out other problems in the ankle such as damage to the cartilage. An MRI typically is not necessary to diagnose a sprain.

What are the treatment options of Ankle Sprain?

Surgery is not required in the vast majority of ankle sprains. Even in severe sprains, these ligaments will heal without surgery. The grade of the sprain will dictate treatment. Sprains are traditionally classified into several grades. Perhaps more important, however, is the patient’s ability to bear weight. Those that can bear weight even after the injury are likely to return very quickly to play. Those who cannot walk may need to be immobilized.

In general, treatment in the first 48 to 72 hours consists of resting the ankle, icing 20 minutes every two to three hours, compressing with an ACE wrap, and elevating, which means positioning the leg and ankle so that the toes are above the level of patient’s nose. Those patients who cannot bear weight are better treated in a removable walking boot until they can comfortably bear weight.

Physical therapy is a mainstay. Patients should learn to strengthen the muscles around the ankle, particularly the peroneals. An ankle brace can be used in an athlete until a therapist believes that the ankle is strong enough to return to play without it. Surgery is rarely indicated but may be needed in a patient who has cartilage damage or other related injuries. Ligaments are only repaired or strengthened in cases of chronic instability in which the ligaments have healed but not in a strong fashion.

How long is the Recovery of Ankle Sprain?

Recovery depends on the severity of the injury. As noted above, for those minor injuries, people can return to their activities in sports within several days. For very severe sprains, it may take longer and up to several weeks. It should be noted that high ankle sprains take considerably longer to heal.

Outcomes for ankle sprains are generally quite good. Most patients heal from an ankle sprain and are able to get back to their normal lives, sports and activities. Some people, however, who do not properly rehab their ankle and have a rather severe sprain may go on to have ankle instability. Chronic instability occurs in patients repeatedly spraining the ankle. Such repeated episodes can be dangerous because they can lead to damage within the ankle. These patients should be identified and considered for repair.

Frequently Asked Questions
What is a high ankle sprain and is that different from a regular ankle sprain?

A high ankle sprain refers to tearing of the ligaments that connect the tibia to the fibula (this connection is also called the syndesmosis). These are different and much less common than the standard lateral ankle sprains, meaning those that occur on the side of the ankle.

Do ankle sprains ever need to be repaired acutely?
Ankle sprains rarely, if ever, needed to be treated with surgery. The vast majority simply need to be treated with rest, ice, compression and elevation followed by physical therapy and temporary bracing.

I have sprained my ankle many times. Should I be concerned?
Yes. The more you sprain an ankle, the greater the chance that problems will develop. For example, turning the ankle can lead to damage to the cartilage inside the ankle joint. You should see your doctor if this is occurring.

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Achilles Tendinitis

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Achilles tendinitis is a common condition that causes pain along the back of the leg near the heel.

The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, and jump.

Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration.

There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed:

– Noninsertional Achilles Tendinitis
In noninsertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to break down with tiny tears (degenerate), swell, and thicken.Tendinitis of the middle portion of the tendon more commonly affects younger, active people.
– Insertional Achilles Tendinitis
Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone.In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Bone spurs (extra bone growth) often form with insertional Achilles tendinitis.Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active.

 Causes of Achilles Tendinitis

Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis, including:

  • Sudden increase in the amount or intensity of exercise activity—for example, increasing the distance you run every day by a few miles without giving your body a chance to adjust to the new distance
  • Tight calf muscles—Having tight calf muscles and suddenly starting an aggressive exercise program can put extra stress on the Achilles tendon
  • Bone spur—Extra bone growth where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain

Symptoms of Achilles Tendinitis

Common symptoms of Achilles tendinitis include:

  • Pain and stiffness along the Achilles tendon in the morning
  • Pain along the tendon or back of the heel that worsens with activity
  • Severe pain the day after exercising
  • Thickening of the tendon
  • Bone spur (insertional tendinitis)
  • Swelling that is present all the time and gets worse throughout the day with activity

If you have experienced a sudden “pop” in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your doctor immediately if you think you may have torn your tendon.

Radiologic Investigation for Achilles Tendinitis

X-rays
X-ray tests provide clear images of bones. X-rays can show whether the lower part of the Achilles tendon has calcified, or become hardened. This calcification indicates insertional Achilles tendinitis. In cases of severe noninsertional Achilles tendinitis, there can be calcification in the middle portion of the tendon, as well.
Magnetic Resonance Imaging (MRI)
Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendinitis, it is important for planning surgery. An MRI scan can show how severe the damage is in the tendon. If surgery is needed, your doctor will select the procedure based on the amount of tendon damage.Treatment of Achilles Tendinitis
Nonsurgical Treatment
In most cases, nonsurgical treatment options will provide pain relief, although it may take a few months for symptoms to completely subside. Even with early treatment, the pain may last longer than 3 months. If you have had pain for several months before seeking treatment, it may take 6 months before treatment methods take effect.

Rest. The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Cross-training activities such as biking, elliptical exercise, and swimming are low-impact options to help you stay active.

Ice. Placing ice on the most painful area of the Achilles tendon is helpful and can be done as needed throughout the day. This can be done for up to 20 minutes and should be stopped earlier if the skin becomes numb. A foam cup filled with water and then frozen creates a simple, reusable ice pack. After the water has frozen in the cup, tear off the rim of the cup. Then rub the ice on the Achilles tendon. With repeated use, a groove that fits the Achilles tendon will appear, creating a “custom-fit” ice pack.

Non-steroidal anti-inflammatory medication. Drugs such as ibuprofen and naproxen reduce pain and swelling. They do not, however, reduce the thickening of the degenerated tendon. Using the medication for more than 1 month should be reviewed with your primary care doctor.

Exercise. The following exercise can help to strengthen the calf muscles and reduce stress on the Achilles tendon.

  • Calf stretch
    Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.

Physical Therapy. Physical therapy is very helpful in treating Achilles tendinitis. It has proven to work better for noninsertional tendinitis than for insertional tendinitis.

Eccentric Strengthening Protocol. Eccentric strengthening is defined as contracting (tightening) a muscle while it is getting longer. Eccentric strengthening exercises can cause damage to the Achilles tendon if they are not done correctly. At first, they should be performed under the supervision of a physical therapist. Once mastered with a therapist, the exercises can then be done at home. These exercises may cause some discomfort, however, it should not be unbearable.

    • Bilateral heel drop
      Stand at the edge of a stair, or a raised platform that is stable, with just the front half of your foot on the stair. This position will allow your heel to move up and down without hitting the stair. Care must be taken to ensure that you are balanced correctly to prevent falling and injury. Be sure to hold onto a railing to help you balance.

Lift your heels off the ground then slowly lower your heels to the lowest point possible. Repeat this step 20 times. This exercise should be done in a slow, controlled fashion. Rapid movement can create the risk of damage to the tendon. As the pain improves, you can increase the difficulty level of the exercise by holding a small weight in each hand.

  • Single leg heel drop
    This exercise is performed similarly to the bilateral heel drop, except that all your weight is focused on one leg. This should be done only after the bilateral heel drop has been mastered.

Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture (tear).

Supportive shoes and orthotics. Pain from insertional Achilles tendinitis is often helped by certain shoes, as well as orthotic devices. For example, shoes that are softer at the back of the heel can reduce irritation of the tendon. In addition, heel lifts can take some strain off the tendon.

Heel lifts are also very helpful for patients with insertional tendinitis because they can move the heel away from the back of the shoe, where rubbing can occur. They also take some strain off the tendon. Like a heel lift, a silicone Achilles sleeve can reduce irritation from the back of a shoe.

If your pain is severe, your doctor may recommend a walking boot for a short time. This gives the tendon a chance to rest before any therapy is begun. Extended use of a boot is discouraged, though, because it can weaken your calf muscle.

Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged tendon tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.

ESWT is noninvasive—it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.

Surgical Treatment

Surgery should be considered to relieve Achilles tendinitis only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the tendinitis and the amount of damage to the tendon.

Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the Achilles tendon, this procedure is useful for patients who still have difficulty flexing their feet, despite consistent stretching.

In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope—an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs.

Complication rates for gastrocnemius recession are low, but can include nerve damage.

Gastrocnemius recession can be performed with or without débridement, which is removal of damaged tissue.

Debridement and repair (tendon has less than 50% damage). The goal of this operation is to remove the damaged part of the Achilles tendon. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures, or stitches to complete the repair.

In insertional tendinitis, the bone spur is also removed. Repair of the tendon in these instances may require the use of metal or plastic anchors to help hold the Achilles tendon to the heel bone, where it attaches.

After débridement and repair, most patients are allowed to walk in a removable boot or cast within 2 weeks, although this period depends upon the amount of damage to the tendon.

Debridement with tendon transfer (tendon has greater than 50% damage). In cases where more than 50% of the Achilles tendon is not healthy and requires removal, the remaining portion of the tendon is not strong enough to function alone. To prevent the remaining tendon from rupturing with activity, an Achilles tendon transfer is performed. The tendon that helps the big toe point down is moved to the heel bone to add strength to the damaged tendon. Although this sounds severe, the big toe will still be able to move, and most patients will not notice a change in the way they walk or run.

Depending on the extent of damage to the tendon, some patients may not be able to return to competitive sports or running.

Recovery. Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage to the tendon. The greater the amount of tendon involved, the longer the recovery period, and the less likely a patient will be able to return to sports activity.

Physical therapy is an important part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.

Complications. Moderate to severe pain after surgery is noted in 20% to 30% of patients and is the most common complication. In addition, a wound infection can occur and the infection is very difficult to treat in this location.

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Achilles Tendon Rupture

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Achilles tendon rupture is an injury that affects the back of your lower leg. It most commonly occurs in people playing recreational sports.

The Achilles tendon is a strong fibrous cord that connects the muscles in the back of your calf to your heel bone. If you overstretch your Achilles tendon, it can tear (rupture) completely or just partially.

If your Achilles tendon ruptures, you might feel a pop or snap, followed by an immediate sharp pain in the back of your ankle and lower leg that is likely to affect your ability to walk properly. Surgery is often the best option to repair an Achilles tendon rupture. For many people, however, nonsurgical treatment works just as well.

Symptoms of Achilles Tendon Rupture

Although it’s possible to have no signs or symptoms with an Achilles tendon rupture, most people experience:

  • Pain, possibly severe, and swelling near your heel
  • An inability to bend your foot downward or “push off” the injured leg when you walk
  • An inability to stand on your toes on the injured leg
  • A popping or snapping sound when the injury occurs

Causes of Achilles Tendon Rupture

Your Achilles tendon helps you point your foot downward, rise on your toes and push off your foot as you walk. You rely on it virtually every time you move your foot.

Rupture usually occurs in the section of the tendon located within 2 1/2 inches (about 6 centimeters) of the point where it attaches to the heel bone. This section may be predisposed to rupture because it gets less blood flow, which also may impair its ability to heal.

Ruptures often are caused by a sudden increase in the amount of stress on your Achilles tendon. Common examples include:

  • Increasing the intensity of sports participation, especially in sports that involve jumping
  • Falling from a height
  • Stepping into a hole

Test and Diagnosis of Achilles Tendon Rupture

During the physical exam, our doctor will inspect your lower leg for tenderness and swelling. In many cases, doctors can feel a gap in your tendon if it has ruptured completely.

The doctor may also ask you to kneel on a chair or lie on your stomach with your feet hanging over the end of the exam table. He may then squeeze your calf muscle to see if your foot will automatically flex. If it doesn’t, you probably have ruptured your Achilles tendon.

If there’s a question about the extent of your Achilles tendon injury whether it’s completely or only partially ruptured, our doctor may order an ultrasound or MRI scan. These painless procedures create images of the tissues of your body.

Treatments of Achilles Tendon Rupture

Treatment for a ruptured Achilles tendon often depends on your age, activity level and the severity of your injury. In general, younger and more active people often choose surgery to repair a completely ruptured Achilles tendon, while older people are more likely to opt for nonsurgical treatment. Recent studies, however, have shown fairly equal effectiveness of both operative and nonoperative management.

Nonsurgical treatment
This approach typically involves wearing a cast or walking boot with wedges to elevate your heel, which allows your torn tendon to heal. This method avoids the risks associated with surgery, such as infection. However, the likelihood of re-rupture may be higher with a nonsurgical approach, and recovery can take longer. If re-rupture occurs, surgical repair may be more difficult.

Surgery
The procedure generally involves making an incision in the back of your lower leg and stitching the torn tendon together. Depending on the condition of the torn tissue, the repair may be reinforced with other tendons. Surgical complications can include infection and nerve damage. Infection rates are reduced in surgeries that employ smaller incisions.

Rehabilitation
After treatment, whether surgical or nonsurgical, you’ll go through a rehabilitation program involving physical therapy exercises to strengthen your leg muscles and Achilles tendon. Most people return to their former level of activity within four to six months.

Prevention of Achilles Tendon Rupture

To reduce your chance of developing Achilles tendon problems, follow these tips:

  • Stretch and strengthen calf muscles. Stretch your calf to the point at which you feel a noticeable pull but not pain. Don’t bounce during a stretch. Calf-strengthening exercises can also help the muscle and tendon absorb more force and prevent injury.
  • Vary your exercises. Alternate high-impact sports, such as running, with low-impact sports, such as walking, biking or swimming. Avoid activities that place excessive stress on your Achilles tendons, such as hill running and jumping activities.
  • Choose running surfaces carefully. Avoid or limit running on hard or slippery surfaces. Dress properly for cold-weather training and wear well-fitting athletic shoes with proper cushioning in the heels.
  • Increase training intensity slowly. Achilles tendon injuries commonly occur after abruptly increasing training intensity. Increase the distance, duration and frequency of your training by no more than 10 percent each week.

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Plantar Fasciitis (Heel Pain)

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Plantar fasciitis  is one of the most common causes of heel pain. It involves pain and inflammation of a thick band of tissue, called the plantar fascia, that runs across the bottom of your foot and connects your heel bone to your toes.

Plantar fasciitis commonly causes stabbing pain that usually occurs with your very first steps in the morning. Once your foot limbers up, the pain of plantar fasciitis normally decreases, but it may return after long periods of standing or after getting up from a seated position.

Plantar fasciitis is particularly common in runners. In addition, people who are overweight and those who wear shoes with inadequate support are at risk of plantar fasciitis.

Symptoms of Plantar Fasciitis
Plantar fasciitis typically causes a stabbing pain in the bottom of your foot near the heel. The pain is usually worst with the first few steps after awakening, although it can also be triggered by long periods of standing or getting up from a seated position.
Causes of Plantar Fasciitis
Plantar fasciitis typically causes a stabbing pain in the bottom of your foot near the heel. The pain is usually worst with the first few steps after awakening, although it can also be triggered by long periods of standing or getting up from a seated position.
Complications of Plantar Fasciitis
Ignoring plantar fasciitis may result in chronic heel pain that hinders your regular activities. If you change the way you walk to minimize plantar fasciitis pain, you might also develop foot, knee, hip or back problems.
Test and Diagnosis of Plantar Fasciitis

During the physical exam, our doctor checks for points of tenderness in your foot. The location of your pain can help determine its cause.

Imaging Tests:

Usually no tests are necessary. The diagnosis is made based on the history and physical examination. Occasionally your doctor may suggest an X-ray or magnetic resonance imaging (MRI) to make sure your pain isn’t being caused by another problem, such as a stress fracture or a pinched nerve.

Sometimes an X-ray shows a spur of bone projecting forward from the heel bone. In the past, these bone spurs were often blamed for heel pain and removed surgically. But many people who have bone spurs on their heels have no heel pain.

Treatment of Plantar Fasciitis

Most people who have plantar fasciitis recover with conservative treatments in just a few months.

Medications
NSAIDs (Non Steroid Anti-Inflammatory Drugs) may ease the pain and inflammation associated with plantar fasciitis.

Therapies
Stretching and strengthening exercises or use of specialized devices may provide symptom relief. These include:

  • Physical therapy. A physical therapist can instruct you in a series of exercises to stretch the plantar fascia and Achilles tendon and to strengthen lower leg muscles, which stabilize your ankle and heel. A therapist may also teach you to apply athletic taping to support the bottom of your foot.
  • Night splints. Your physical therapist or doctor may recommend wearing a splint that stretches your calf and the arch of your foot while you sleep. This holds the plantar fascia and Achilles tendon in a lengthened position overnight and facilitates stretching.
  • Orthotics. Your doctor may prescribe off-the-shelf heel cups, cushions or custom-fitted arch supports (orthotics) to help distribute pressure to your feet more evenly.

Surgical or other procedures
When more-conservative measures aren’t working, your doctor might recommend:

  • Steroid shots. Injecting a type of steroid medication into the tender area can provide temporary pain relief. Multiple injections aren’t recommended because they can weaken your plantar fascia and possibly cause it to rupture, as well as shrink the fat pad covering your heel bone.
  • Extracorporeal shock wave therapy. In this procedure, sound waves are directed at the area of heel pain to stimulate healing. It’s usually used for chronic plantar fasciitis that hasn’t responded to more-conservative treatments. This procedure may cause bruises, swelling, pain, numbness or tingling and has not been shown to be consistently effective.
  • Surgery. Few people need surgery to detach the plantar fascia from the heel bone. It’s generally an option only when the pain is severe and all else fails. Side effects include a weakening of the arch in your foot.

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Wrist Ganglion Cyst

Ganglion cysts are the most common mass or lump in the hand. They are not cancerous and, in most cases, are harmless. They occur in various locations, but most frequently develop on the back of the wrist.

These fluid-filled cysts can quickly appear, disappear, and change size. Many ganglion cysts do not require treatment. However, if the cyst is painful, interferes with function, or has an unacceptable appearance, there are several treatment options available.

A ganglion rises out of a joint, like a balloon on a stalk. It grows out of the tissues surrounding a joint, such as ligaments, tendon sheaths, and joint linings. Inside the balloon is a thick, slippery fluid, similar to the fluid that lubricates your joints.

Ganglion cysts can develop in several of the joints in the hand and wrist, including both the top and underside of the wrist, as well as the end joint of a finger, and at the base of a finger. They vary in size, and in many cases, grow larger with increased wrist activity. With rest, the lump typically becomes smaller.

Causes of Ganglion Cyst

It is not known what triggers the formation of a ganglion. They are most common in younger people between the ages of 15 and 40 years, and women are more likely to be affected than men. These cysts are also common among gymnasts, who repeatedly apply stress to the wrist.

Ganglion cysts that develop at the end joint of a finger also known as mucous cysts are typically associated with arthritis in the finger joint, and are more common in women between the ages of 40 and 70 years.

Symptoms of Ganglion Cyst

Most ganglions form a visible lump, however, smaller ganglions can remain hidden under the skin (occult ganglions). Although many ganglions produce no other symptoms, if a cyst puts pressure on the nerves that pass through the joint, it can cause pain, tingling, and muscle weakness.

Large cysts, even if they are not painful, can cause concerns about appearance.

Doctor Examination of Ganglion Cyst

  • Medical History and Physical Examination
  • During the initial appointment, your doctor will discuss your medical history and symptoms. He or she may ask you how long you have had the ganglion, whether it changes in size, and whether it is painful.

Pressure may be applied to identify any tenderness. Because a ganglion is filled with fluid, it is translucent. Your doctor may shine a penlight up to the cyst to see whether light shines through.

  • Imaging Tests

X-rays. These tests create clear pictures of dense structures, like bone. Although x-rays will not show a ganglion cyst, they can be used to rule out other conditions, such as arthritis or a bone tumor.

Magnetic resonance imaging (MRI) scans or ultrasounds. These imaging tests can better show soft tissues like a ganglion. Sometimes, an MRI or ultrasound is needed to find an occult ganglion that is not visible, or to distinguish the cyst from other tumors.

Heberden’s Nodes

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Bony bumps on the finger joint closest to the fingernail are called Heberden’s nodes. Bony bumps on the middle joint of the finger are known as Bouchard’s nodes.

Bony bumps are also common at the base of the thumb. These bumps do not have a nickname, but the joint is called the CMC or carpometacarpal joint. The name comes from the bone of the wrist (carpal) and the bone of the thumb (metacarpal).

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Heberden’s nodes typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways. Bouchard’s nodes may also be present; these are similar bony growths in the proximal interphalangeal (PIP) joints (middle joints of the fingers), and are also associated with osteoarthritis.

Heberden’s nodes are more common in women than in men, and there seems to be a genetic component involved in predisposition to the condition.

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Hand and Finger Arthritis

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Rheumatoid arthritis (RA) is a painful inflammatory disease that causes swelling, stiffness, joint destruction, and deformity. This autoimmune disease has an effect on the cells that coat and lubricate joints (synovial tissue).

Osteoarthritis (the “wear and tear” arthritis”) may often affect just one joint even though it can affect multiple joints. Rheumatoid arthritis, though, typically affects multiple joints and  usually happens symmetrically. For instance, RA may affect  the same joint group on both sides of the body.

What are the symptoms of Hand and Finger Arthritis?

The wrist joints and the finger joints are common targets of RA. With hand and finger RA, you may experience the following:

  • Hand pain, finger pain, swelling, and stiffness
  • Hand joints and finger joints that are warm and tender to the touch
  • The same joints affected symmetrically (both wrists and fingers on both hands)
  • Deformities in finger joints
  • Carpal tunnel symptoms such as numbness and tingling of the hands
  • Flu-like feeling
  • Fatigue that is not easily resolved
  • Pain and stiffness that last for more than an hour upon arising

What causes Rheumatoid Arthritis?

Scientists are unsure about the causes of RA. They do know that RA affects about 1.3 million Americans and occurs in all racial and ethnic groups. About two to three times as many women suffer from rheumatoid arthritis as men. Some rheumatoid arthritis research points to the following factors as possibly influencing rheumatoid arthritis:

  • Genetic factors.
  • Environmental factors such as a viral or bacterial infection.
  • Hormones. RA tends to improve with pregnancy. Breastfeeding, and the postpartum period (the time after delivery), however, may aggravate rheumatoid symptoms.

What is a swan-neck deformity?

Rheumatoid arthritis is a common cause of a swan-neck deformity.

With a swan-neck deformity, the base of the finger and the outermost joint bend, while the middle joint straightens. Over time, this imbalance of the finger joints can result in the crooked swan-neck position. (True swan-neck deformity does not occur in the thumb).

A swan-neck deformity can make it almost impossible to bend the affected finger normally; it can make it difficult to button shirts, grip a glass, or pinch with the fingers.

By examining the hand and fingers, a rheumatologist can diagnose a swan-neck deformity and determine appropriate treatment, which may include:

  • Finger splints or ring splints
  • Surgery to realign the joints or fuse the joints for better function

What is a boutonniere deformity?

Boutonniere deformity, also called buttonhole deformity, can occur as a result of rheumatoid arthritis.

With a boutonniere deformity, the middle finger joint will bend toward the palm while the outer finger joint may bend opposite the palm. This deformity may be the result of chronic inflammation of the finger’s middle joint.

Treatment for boutonniere deformity may include splinting to keep the middle joint extended. Surgery may be needed.

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Trigger Finger

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Trigger finger is a painful condition that causes the fingers or thumb to catch or lock when bent. In the thumb its called trigger thumb.
Trigger finger happens when tendons in the finger or thumb become inflamed. Tendons are tough bands of tissue that connect muscles and bones. Together, the tendons and muscles in the hands and arms bend and straighten the fingers and thumbs.

A tendon usually glides easily through the tissue that covers it (called a sheath) because of a lubricating membrane surrounding the joint called the synovium. Sometimes a tendon may become inflamed and swollen. When this happens, bending the finger or thumb can pull the inflamed tendon through a narrowed tendon sheath, making it snap or pop.

trigger-finger

What causes Trigger Finger?

Trigger finger can be caused by a repeated movement or forceful use of the finger or thumb. Rheumatoid arthritis, gout, and diabetes also can cause trigger finger. So can grasping something, such as a power tool, with a firm grip for a long time.

Who gets Trigger Finger?
Farmers, industrial workers, and musicians often get trigger finger since they repeat finger and thumb movements a lot. Even smokers can get trigger thumb from repeated use of a lighter, for example. Trigger finger is more common in women than men and tends to happen most often in people who are 40 to 60 years old.

What are the symptoms of Trigger Finger?
One of the first symptoms of trigger finger is soreness at the base of the finger or thumb. The most common symptom is a painful clicking or snapping when bending or straightening the finger. This catching sensation tends to get worse after resting the finger or thumb and loosens up with movement.

In some cases, the finger or thumb locks in a bent or straight position as the condition gets worse and must be gently straightened with the other hand.

 How is Trigger Finger diagnosed?
Trigger finger is diagnosed with a physical exam of the hand and fingers. In some cases, the finger may be swollen and there may be a bump over the joint in the palm of the hand. The finger also may be locked in bent position, or it may be stiff and painful. No X-rays or lab tests are used to diagnose trigger finger.

How is Trigger Finger treated?
The first step is to rest the finger or thumb. Our doctor may put a splint on the hand to keep the joint from moving. If symptoms continue, our doctor may prescribe drugs that fight inflammation. Our doctor may also recommend an injection of anti-inflammatory medicine into the tendon sheath. If the trigger finger does not get better, our doctor may recommend surgery of Trigger Finger Release.

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Mallet Finger (Baseball Finger)

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A mallet finger is a deformity of a finger caused when a certain tendon (the extensor tendon) is damaged. When a ball or other object strikes the tip of the finger or thumb, the force damages the thin tendon that straightens the finger. The force of the blow may even pull away a piece of bone along with the tendon. The finger or thumb is not able to be straightened. This condition is also known as baseball finger.

Symptoms of Mallet Finger

The finger is usually painful, swollen, and bruised. The fingertip may droop noticeably. Occasionally, blood collects beneath the nail. The nail can even become detached from beneath the skin fold at the base of the nail.

Diagnosis of Mallet Finger

In most cases, the doctor will order X-rays in order to look for a major fracture or malalignment of the joint.

Non-Surgical Treatment of Mallet Finger
The majority of mallet finger injuries can be treated without surgery. Ice should be applied immediately and the hand should be elevated above the level of the heart. Medical attention should be sought within a week after injury. It is very important to seek immediate attention if there is blood beneath the nail or if the nail is detached. This may be a sign of nail bed laceration or open (compound) fracture.

The doctor may apply a splint to hold the fingertip straight (in extension) until it heals. Most of the time, a splint will be worn full time for eight weeks. Over the next three to four weeks, most patients gradually begin to wear the splint less frequently. Although the finger usually regains an acceptable function and appearance with this treatment plan, many patients may not regain full fingertip extension.

In children, mallet finger injuries may involve the cartilage that controls bone growth. The doctor must carefully evaluate and treat this injury in children, so that the finger does not become stunted or deformed.

Surgical Treatment of Mallet Finger
Surgical repair may be considered when mallet finger injuries also show signs of large fracture fragments or joint malalignment. In these cases, surgery is done to repair the fracture using pins, pins and wire, or even small screws. Surgery may also be considered if nonsurgical treatment fails.
It is not common to treat a mallet finger surgically if bone fragments or fractures are not present. This is usually reserved for patients who have a very severe deformity or who cannot use their finger properly. Surgical treatment of the damaged tendon can include tightening the stretched tendon tissue, using tendon grafts, or even fusing the joint straight.
An orthopaedic surgeon should be consulted in making the decision to treat this condition surgically.

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Ingrown Toenail

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Ingrown toenail is toenail having its free tip or edges embedded in the surrounding flesh or nails whose corners or sides dig painfully into the skin of the toe.

Definition of Ingrown Toenail:

An ingrown toe nail is a painful condition of the toe. It occurs when a sharp corner of the toenail digs into the skin at the end or side of the toe. Pain and inflammation at the spot where the nail curls into the skin occurs first. The inflamed area then starts to grow extra tissue or drain yellowish fluid.

Ingrown Toenail

What are the causes of Ingrown Toenail?

Ingrown toe nail can be caused by tight-fitting shoes or high heels causing the toes to be compressed together and pressurize the nail to grow abnormally. Improper trimming of toenails can also cause the corners of the nail to dig into the skin. Disorders such as fungal infections of the nail can also cause a thickened or widened toenail to develop.

How to prevent Ingrown Toenail?

The best method of prevention is careful clipping of the toenails. Toenails should be clipped straight across and taking care to keep the end longer than the skin edge. This prevents the corners from digging into the skin. They should not be rounded or cut too short. Wearing well-fitting shoes helps as well.

What are the treatments for Ingrown Toenail?

Mild ingrown toenails may be treated with conservative measures like warm daily soaks, topical antibiotics, and gently pushing back the piece of overgrown skin away from the nail. More advanced ingrown toenails may require treatment with oral antibiotics. Resistant or recurrent cases of ingrown toenails may require a minor in-office procedure. Surgical procedures aim to remove the nail’s matrix so that this will be permanent solution for Ingrown Toe Nail.

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De Quervain’s Stenosing Tenosynovitis (Wrist Pain)

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De Quervain’s tenosynovitis  is a painful condition affecting the tendons on the thumb side of your wrist. If you have de Quervain’s tenosynovitis, it will probably hurt every time you turn your wrist, grasp anything or make a fist.

Although the exact cause of de Quervain’s tenosynovitis isn’t known, any activity that relies on repetitive hand or wrist movement such as working in the garden, playing golf or racket sports or lifting your baby can make it worse.

Symptoms of de Quervain’s tenosynovitis include:

  • Pain near the base of your thumb
  • Swelling near the base of your thumb
  • Difficulty moving your thumb and wrist when you’re doing activities that involve grasping or pinching
  • A “sticking” or “stop-and-go” sensation in your thumb when trying to move it

If the condition goes too long without treatment, the pain may spread farther into your thumb, back into your forearm or both. Pinching, grasping and other movements of your thumb and wrist aggravate the pain.

When to see a doctor
Consult your doctor if you’re still having problems with pain or function and you’ve already tried:

  • Avoiding moving your thumb in the same way over and over again whenever possible
  • Avoiding pinching with your thumb when moving your wrist from side to side
  • Applying cold to the affected area
  • Using nonsteroidal anti-inflammatory drugs.

If the pain continues to interfere with your daily life or activities, seek medical advice.

Causes for De Quervain’s Tenosynovitis

Chronic overuse of your wrist is commonly associated with de Quervain’s tenosynovitis.

When you grip, grasp, clench, pinch or wring anything in your hand, you use two major tendons in your wrist and lower thumb. These tendons normally glide unhampered through the small tunnel that connects them to the base of the thumb. If you repeat a particular motion day after day, it may irritate the sheath around the two tendons, causing thickening that restricts the movement of the tendons.

Other causes of de Quervain’s tenosynovitis include:

  • Direct injury to your wrist or tendon; scar tissue can restrict movement of the tendons
  • Inflammatory arthritis, such as rheumatoid arthritis

If de Quervain’s tenosynovitis is left untreated, it may be hard to use your hand and wrist properly. If the affected tendons are no longer able to slide within their tunnel, you may develop a limited range of motion.

Tests and Diagnostic of the De Quervain Tenosynovitis

To diagnose de Quervain’s tenosynovitis, your doctor will examine your hand to see if you feel pain when pressure is applied on the thumb side of the wrist.

Your doctor will also perform a test called the Finkelstein test. In a Finkelstein test, you bend your thumb across the palm of your hand and bend your fingers down over your thumb. Then you bend your wrist toward your little finger. If this causes pain on the thumb side of your wrist, you likely have de Quervain’s tenosynovitis.

Imaging tests, such as X-rays, generally aren’t needed to diagnose de Quervain’s tenosynovitis.

Treatment for De Quervain’s Tenosynovitis

Treatment for de Quervain’s tenosynovitis may include medications, physical or occupational therapy, or surgery. Treatment is generally successful if begun early on, though the pain may recur if you can’t discontinue the repetitive motions that aggravate your condition. If you start treatment early on, your symptoms of de Quervain’s tenosynovitis should generally improve within four to six weeks. When de Quervain’s tenosynovitis starts during pregnancy, symptoms usually get better around the end of pregnancy or when breast-feeding stops.

Medications
To reduce pain and swelling, your doctor may recommend using non steroid anti-inflammatory injection.

Our doctor may also recommend injections into the tendon sheath to reduce swelling. If treatment begins within the first six months of symptoms, most people recover completely after receiving injections, often after just one injection.

Therapy
Initial treatment of de Quervain’s tenosynovitis may include:

  • Immobilizing your thumb and wrist, keeping them straight with a splint or brace to help rest your tendons
  • Avoiding repetitive thumb movements whenever possible
  • Avoiding pinching with your thumb when moving your wrist from side to side
  • Applying ice to the affected area

You may also see a physical or occupational therapist. These therapists may review your habits and give suggestions on how to make necessary adjustments to relieve stress on your wrists. Your therapist can also teach you exercises focused on your wrist, hand and arm to strengthen your muscles, reduce pain, and limit the irritation of the tendons. The therapist may also make a splint to keep your wrist and thumb from moving if off-the-shelf versions don’t fit you well.

Surgery
If your case is more serious, your doctor may recommend outpatient surgery. Surgery involves a procedure in which your doctor inspects the sheath surrounding the involved tendon or tendons, and then opens the sheath to release the pressure and restore free tendon gliding.

Our Doctor will talk to you about how to rest, strengthen and rehabilitate your body after surgery. A physical or occupational therapist may meet with you after surgery to teach you new strengthening exercises and help you adjust your daily routine to prevent future problems.

Cure your Wrist Pain Today. Effective treatment, Non Surgery. Discuss with our Hand Specialist for the Diagnosis, Treatment and Prognosis of your Wrist Pain. Call us +65 97731458 to schedule for an appointment.

Carpal Tunnel Syndrome

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Definition of Carpal Tunnel Syndrome:

There are several common causes of hand tingling. Carpal tunnel syndrome tends to be one of the most common causes of hand tingling. One of the nerves that supply the hand is called the Median nerve. This nerve travels across the wrist to supply the fingers. With repetitive bending and straightening of the wrist this nerve gets injured. This tends to occur in people that use the computer frequently, use the cash register, or are involved in activities that involve repetitive motion at the wrist.

Another nerve that supplies the hand is called the Ulnar nerve. This nerve passes behind the elbow and could get injured at that point. One of the common causes of injury is from leaning on the elbow which causes pressure on the nerve. Other common causes include pressure from surrounding tissue, arthritis, and injury to the elbow.

Since the nerves that supply the hands originate in the spine, injury to the nerves at this level could cause numbness, tingling, and weakness in the hands. Generally patients often have shooting pain down the arm with this kind of a problem. There could be multiple causes like disk disease, tumors, and arthritis.

Systemic disease like diabetes, kidney failure, infections, and others could cause injury to the nerves so that patients could develop weakness and numbness in their hands. These patients often also have numbness and tingling in their feet first. These patients most often have Neuropathy.

Carpal tunnel syndrome occurs when the median nerve which runs from the forearm into the hand becomes pressed or squeezed at the wrist. This results in pain, weakness, or numbness in the hand and wrist, radiating up the arm.

Hand and Wrist Pain

How is Carpal Tunnel Syndrome Diagnosed?
A physical examination help determine if the syndrome are related to daily activities or to an underlying disorder and can rule out other painful conditions that mimic carpal tunnel syndrome.

Electromyography is often used to confirm the diagnosis. This involves a fine needle being inserted into a muscle where electrical activities are viewed on a screen determining the severity of damage to the median nerve. Ultrasound imaging can also show impaired movement of the median nerve.

What are the causes of Carpal Tunnel Syndrome?
Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself. Most likely the disorder is due to a congenital predisposition. Other contributing factors include trauma or injury to the wrist that cause swelling, such as sprain or fracture. It can also be caused by medical conditions such as diabetes, arthritis, pregnancy and obesity.

What are the treatments of Carpal Tunnel Syndrome?
Treatments for carpal tunnel syndrome should begin as early as possible under a doctor’s direction. Initial treatment generally involves resting the affected hand and wrist for at least 2 weeks, avoiding activities that may worsen symptoms and immobilizing the wrist in a splint to avoid further damage from twisting or bending. If there is inflammation, applying cool packs can help reduce swelling. In early stage of Carpal Tunnel Syndrome, Injection will be one of the effective way in treating this condition. Surgery is recommended if symptoms last for more than 9-12 months. Surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve.

Cure Carpal Tunnel Syndrome today. Effective treatment, Non Surgery. Call us +65 97731458 to schedule for an appointment.

Plantar Fasciitis (Heel Pain)

Heel pain is sometimes associated directly with plantar fasciitis, an inflammation of the plantar fascia at the bottom of the foot.

Plantar fasciitis is the most common cause of heel pain. It is caused by repeated strain on the plantar fascia, the ligament that connects the heel bone to the toes, supporting the arch of the foot. A strained plantar fascia causes weakness, swelling, and inflammation, especially in one or both heels. Causes of plantar fasciitis include rolling the feet inward while walking; having high arches or flat feet; and running, walking, or standing for along periods of time. Symptoms include pain upon waking and pain while walking and climbing stairs.

Definition of Plantar Fasciitis:
Plantar fasciitis is one of the most common causes of heel pain. It is due to inflammation of a thick band of tissue called the plantar fascia, which runs across the bottom of the foot, connecting the heel bone to the toes.

How is heel pain (plantar fasciitis) diagnosed?
The chief diagnostic sign of these problems is pain in the bottom of the heel or arch when first standing, which gradually improves with walking. This pain may later return with continued walking. The pain usually subsides after a period of rest.

What are the causes of Plantar Fasciitis?
Under normal circumstances, the plantar fascia acts like a shock-absorbing bowstring, supporting the arch of the foot. But when the tension on the bowstring becomes too great, it creates small tears in the fascia. Repetitive stretching and tearing causes the fascia to become irritated or inflamed.

How to prevent heel pain (plantar fasciitis)?
Maintaining a healthy weight minimizes the stress on the plantar fascia and choosing supportive shoes by avoiding high heels and buy shoes with a low to moderate heel, good arch support and shock absorbency. Do not go barefoot, especially on hard surfaces.

What are the treatment options available for plantar fasciitis?
About 90 percent of people who suffer from plantar fasciitis recover with conservative treatments in just a few months. Anti-inflammatory drugs will be able to reduce pain and inflammation, although they do not treat the underlying problem. Anti-inflammatory injection will help to reduce the inflammation of the soft tissue. If the symptom persisted, Shockwave therapy or Platelet Rich Plasma (PRP) therapy may be performed to treat the plantar fasciitis.

When does surgery for plantar fasciitis become a treatment option?
Surgery should be reserved for patients who have made every effort to fully participate in conservative treatments, but continue to have pain from plantar fasciitis. Patients should fit the following criteria:

  • Symptoms for at least 6 months of treatment
  • Participation in daily treatments (exercises, stretches, etc.)
  • Understanding of the potential risks and benefits of surgery

If you fit these criteria, then surgery may be an option in the treatment of your plantar fasciitis.

Ulnar Nerve Neuritis

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What is Ulnar Nerve Neuritis?
One of the nerves that supplies the hand is called the ‘ulnar nerve’. Like a telephone cable, it passes through a protective conduit (a tunnel) behind the inner bony prominence of the elbow. This bony prominence is called the ‘medial epicondyle’ (the ‘funny bone’). The other bony prominence is the tip of the elbow. The tunnel is between these bony prominences and is called the ‘cubital tunnel’. The roof of the tunnel is formed by a band that attaches to these bony prominences (‘Osbourne’s ligament’). The nerve can get compressed in this tunnel and cause symptoms. The condition is known as a ‘Cubital Tunnel Syndrome’.

 

What is the cause?
This is the second most common cause of nerve entrapment. In the majority of patients, we do not know what causes this syndrome. Mechanically the nerve gets stretched every time we bend the elbow and it pushes against the medial epicondyle. With time this causes irritation and compression of the nerve. It usually occurs in middle age. The condition is associated with diabetes, previous elbow injuries/fractures, arthritis & rheumatoid disease.

What are the symptoms and how is the condition diagnosed?
The main symptom is tingling or pins and needles in the hand. The symptoms usually affect the little finger and ring fingers. This is because the ulnar nerve supplies sensations to these fingers. Tingling is often worse at night or first thing in the morning. This is because most people sleep with their elbows bent or with their arms above their head.

In the early stages, the symptoms are intermittent but later become continuous as the condition worsens. Patients may initially complain of pain on the inner aspect of the elbow and will notice numbness in the fingers. Later symptoms of weakness and wasting of the muscles of the hand may develop. The most commonly wasted muscle mass is in the first web space, on the back of the hand between the thumb and the index finger. Patients may drop objects and feel clumsy with their hand(s).

The diagnosis is further confirmed by various clinical tests that assess the strengths of various muscles supplied by the median nerve.

Will further tests or investigations be needed?
The diagnosis of cubital tunnel syndrome is made clinically but you will nearly always be referred for electical tests (nerve conduction studies). The tests may be to confirm the diagnosis in patients in whom the symptoms and signs are not typical, and also to confirm that the nerve is not compressed elsewhere (usually in the neck from where it begins or rarely on the front of the wrist).

What is the treatment?

  • Splints: They keep the elbow from bending and may be useful if worn at night. Instead of an expensive splint you could wrap a towel round the elbow and hold it in place with a tape (like a pig in a blanket). Avoid activities that keep the elbow bent for a long time. Keep more space between your work and your chest when working at the desk to keep the elbows more straight.
  • Surgery: The primary aim of surgery is to prevent deterioration by creating more space for the nerve and to reduce pressure on the nerve. There are several methods described but the choice of the operation depends on the surgeons’ experience and anatomy of the ulnar nerve and the elbow.

Decompression of the ulnar nerve: This is a standard operation advised and is an open surgical release of the cubital tunnel. A skin incision of 5 cm is required and at surgery the roof of the cubital tunnel is opened, thereby decompressing the ulnar nerve. The procedure can be carried out under local or general anaesthesia, as a day case. At surgery a tourniquet cuff is applied around the arm so as to stop bleeding and make the operation safer and quicker. This tourniquet is needed for about 15 minutes and can be uncomfortable when the operation is carried out under local anaesthesia. After the operation, a sticky dressing is applied over the surgical wound. A bulky supportive cotton-wool dressing then goes on top of that. This supportive dressing is reduced after a couple of days. The small sticky dressing should be left for 10 -12 days when the stitches will need to come out. The arm should be kept elevated after surgery for 1-2 days as this will prevent the fingers swelling and causing discomfort. Light use of the limb should be possible immediately after the day of surgery. Active movements of the fingers/ wrist/ shoulder are recommended soon after surgery.

Endoscopic decompression of the cubital tunnel: Some surgeons advise endoscopic decompression of the cubital tunnel (key hole surgery). A telescope is used and surgery is visualized on a television monitor. A smaller incision is needed and an earlier return to work is possible. The risks associated with the procedure are greater. It is debatable as to whether the benefits of this procedure significantly outweigh the risks.

Ulnar nerve transposition: This is another common type of surgery where the ulnar nerve is moved from behind the funny bone, to beneath the muscle on the front of the funny bone. This way, the nerve will not stretch when the elbow is bent. In about 7-10% of patients the ulnar nerve can flip to the front of the elbow by itself (subluxing nerve) and this operation will be considered. Similarly this is the operation of choice for patients with an elbow deformity.

Medial epicondylectomy: This operation is sometimes advised, though less commonly in this UK. Here, the funny bone is removed allowing the nerve to move freely as the patient bends the elbow.

  • When certain other conditions like (rheumatoid) arthritis are present, clearing of the soft tissue lining (synovectomy) or excision of any bony spurs, may be needed.

What happens if it is not treated?
Some mild cases of cubital tunnel syndrome may recover spontaneously. If the condition is neglected most people will find that symptoms become progressively worse. The ulnar nerve will continue to be compressed, resulting in total, constant numbness, due to wasting and weakness of the muscles supplied by the nerve in the hand. This will lead to permanent, irreversible muscle weakness, affecting functionality.

What is the success of surgical treatment?
The operation has a very good success rate in the early stages. It results in good resolution of night pain and tingling within a few days. However if the condition has been present for a long time, then recovery from symptoms of constant numbness and muscle weakness is unpredictable. However one of the aims and benefits of surgery is to stop the nerve from deteriorating due to constant compression. Thus even if the procedure does not reverse the symptoms, it will help to prevent progressive worsening of the nerve function.

What are the complications of surgical treatment?
The surgical scar may appear reddish for 2-3 weeks and may be tender for 6-8 weeks. However it is seldom troublesome in the longer term. An area of numbness may persist around the scar.

Infection of the wound is possible and in the early stages can be successfully treated with antibiotics. If pain increases after surgery infection needs to be ruled out.

Stiffness of the upper limb joints is possible and hence the need to exercise the limb soon after surgery. Severe complex regional pain syndrome (CRPS) is a rare but serious complication after upper limb surgery. Unfortunately it is not possible to predict this problem but needs to be watched and treated (usually with just physiotherapy) if it develops.

Damage to the ulnar nerve is possible but very rare when the open surgical technique is used. The risk is higher when the endoscopic technique is used.

Any surgical intervention has the risk of developing unpredicted complications or setbacks. These complications may have the potential to leave the patient worse than before surgery.

Is there anything I can do to improve outcome?

  • After surgery keep the hand up so as to help reduce swelling.
  • It is advised against wearing rings on the operated hand for 4-6 weeks following surgery.
  • Start exercising your limb immediately after surgery (Make a fist, and then stretch your fingers out; bend your wrist forwards and backwards and touch each finger tip in turn with your thumb). This will help avoid finger swelling and stiffness.
  • Keep the wound dry.
  • Once the stitches have come out the scar can be massaged regularly with a soft non-perfumed cream for a couple of months.
  • If the scar is tender to press, tapping along the scar and on either side of it firmly with your fingertips a few times a day may be useful.

When can I do various activities?
Return to work depends on many factors including the nature of the job and hand dominance.

  • Generally patients can return to a desk job within a few days and perform reasonable tasks with the hand.
  • Avoid pressing heavily on the scar.
  • Manual work should be avoided for 4-6 weeks.
  • Driving should be possible within a week of the operation.

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Olecranon Bursitis (Elbow Bursitis)

Get professional Opinion and Treatment about your Olecranon Bursitis (Elbow Bursitis). Effective and fast relief treatment by Experienced Elbow Specialist. Call us +65 97731458 to schedule for an appointment.

Elbow bursitis, also called olecranon bursitis, causes fluid to collect in a sac that lies behind the elbow, called the olecranon bursa. A bursa is a slippery, sac-like tissue that normally allows smooth movement around bony prominences, such as the point behind the elbow. When a bursa becomes inflamed, the sac fills with fluid. This can cause pain and a noticeable swelling behind the elbow.

Why did I get elbow bursitis?

Elbow bursitis may follow a traumatic accident, such as a fall onto the back of the elbow, or it may seemingly pop up out of nowhere. People who rest their elbows on hard surfaces may aggravate the condition and make the swelling more prominent.

How is the diagnosis of elbow bursitis made?

The common symptoms of elbow bursitis include:

  • Pain around the back of the elbow
  • Swelling directly over the bony prominence of the tip of the elbow
  • Slightly limited motion of the elbow

There are other conditions that can cause elbow pain and swelling, and these should also be considered as a possible diagnosis. Your doctor can usually diagnose elbow bursitis on examination, but an x-ray will often be done to ensure the elbow joint itself appears normal. A MRI is not necessary to diagnose elbow bursitis, and will only be done if there is uncertainty about the diagnosis.

Are the complications of elbow bursitis?

Occasionally, the swelling and inflammation can be the result of an infection within the bursa, this is called infected elbow bursitis. Patients with systemic inflammatory conditions, such as gout and rheumatoid arthritis, are also at increased risk of developing infected elbow bursitis.

Get professional Opinion and Treatment about your Olecranon Bursitis (Elbow Bursitis). Effective and fast relief treatment by Experienced Elbow Specialist. Call us +65 97731458 to schedule for an appointment.

Dr Ambrose Yung Wai Yin

Dr Ambrose Yung

Dr Ambrose Yung

Dr Ambrose Yung is a specialist orthopaedic consultant with experience in partial knee replacement, complex primary total knee replacement, revision knee replacement, minimal invasive knee and shoulder sports surgery.

After his orthopaedic specialist qualification, he was awarded 1-year fellowship in world renowned Nuffield Orthopaedic Centre, Oxford University Hospital and Hip & Knee Division, Southampton University Hospital. During his fellowship, he was well trained in minimal invasive partial knee replacement and complex total knee replacement, computer navigational partial and total knee replacement.

Dr Yung was awarded Minister for Health Award, Singapore for his contribution to medical relief in Indonesian Earthquake, 2006. After his voluntary medical work in SARS 2003, he was awarded Certificate of Honor, Hospital Authority of Hong Kong for his contribution in fighting against SARS.

He is Senior Clinical Lecturer in Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, and Clinical Physician Faculty, Singhealth Residency.

Dr Ambrose Yung Wai Yin 

翁偉賢医生

Specialist Consultant Orthopaedic Surgeon
MBBS (HK), MRCS (Edin), MMED (Ortho), FRCS (Ortho)
Special interest in Sports Medicines, Partial & Total Joint Replacement, Minimal Invasive Trauma Surgery

Platelet Rich Plasma (PRP)

Platelet Rich Plasma (PRP) therapy holds Great Promise to heal the Soft Tissue, Chronic Tendon Injury, Knee Osteoarthritis, Sports Injury, Acute Ligament and Muscle Injury. Get your PRP done with us today. Call us at +65 97731458 to schedule for an appointment

During the past several years, much has been written about a preparation called platelet-rich plasma (PRP) and its potential effectiveness in the treatment of injuries.

Many famous athletes Tiger Woods, tennis star Rafael Nadal, and several others have received PRP for various problems, such as sprained knees and chronic tendon injuries. These types of conditions have typically been treated with medications, physical therapy, or even surgery. Some athletes have credited PRP with their being able to return more quickly to competition.

Platelet Rich Plasma

What is Platelet Rich Plasma (PRP)?

Although blood is mainly a liquid (called plasma), it also contains small solid components (red cells, white cells, and platelets.) The platelets are best known for their importance in clotting blood. However, platelets also contain hundreds of proteins called growth factors which are very important in the healing of injuries.

PRP is plasma with many more platelets than what is typically found in blood. The concentration of platelets and, thereby, the concentration of growth factors can be 5 to 10 times greater (or richer) than usual.

To develop a PRP preparation, blood must first be drawn from a patient. The platelets are separated from other blood cells and their concentration is increased during a process called centrifugation. Then the increased concentration of platelets is combined with the remaining blood.

How does Platelet Rich Plasma (PRP) works?

Although it is not exactly clear how PRP works, laboratory studies have shown that the increased concentration of growth factors in PRP can potentially speed up the healing process.

To speed healing, the injury site is treated with the PRP preparation. This can be done in one of two ways:

  • PRP can be carefully injected into the injured area. For example, in Achilles tendonitis, a condition commonly seen in runners and tennis players, the heel cord can become swollen, inflamed, and painful. A mixture of PRP and local anesthetic can be injected directly into this inflamed tissue. Afterwards, the pain at the area of injection may actually increase for the first week or two, and it may be several weeks before the patient feels a beneficial effect.
  • PRP may also be used to improve healing after surgery for some injuries. For example, an athlete with a completely torn heel cord may require surgery to repair the tendon. Healing of the torn tendon can possibly be improved by treating the injured area with PRP during surgery. This is done by preparing the PRP in a special way that allows it to actually be stitched into torn tissues.

What conditions are treated with Platelet Rich Plasma (PRP)?

Research studies are currently being conducted to evaluate the effectiveness of PRP treatment. At this time, the results of these studies are inconclusive because the effectiveness of PRP therapy can vary. Factors that can influence the effectiveness of PRP treatment include:

  • The area of the body being treated
  • The overall health of the patient
  • Whether the injury is acute (such as from a fall) or chronic (an injury developing over time)

– Chronic Tendon Injuries

According to the research studies currently reported, PRP is most effective in the treatment of chronic tendon injuries, especially tennis elbow, a very common injury of the tendons on the outside of the elbow.

The use of PRP for other chronic tendon injuries such as chronic Achilles tendonitis or inflammation of the patellar tendon at the knee (jumper’s knee) is promising. However, it is difficult to say at this time that PRP therapy is any more effective than traditional treatment of these problems.

– Acute Ligament and Muscle Injuries
Much of the publicity PRP therapy has received has been about the treatment of acute sports injuries, such as ligament and muscle injuries. PRP has been used to treat professional athletes with common sports injuries like pulled hamstring muscles in the thigh and knee sprains. There is no definitive scientific evidence, however, that PRP therapy actually improves the healing process in these types of injuries.

– Surgery
More recently, PRP has been used during certain types of surgery to help tissues heal. It was first thought to be beneficial in shoulder surgery to repair torn rotator cuff tendons. However, the results so far show little or no benefit when PRP is used in these types of surgical procedures.Surgery to repair torn knee ligaments, especially the anterior cruciate ligament (ACL) is another area where PRP has been applied. At this time, there appears to be little or no benefit from using PRP in this instance.
– Knee Arthritis
Some initial research is being done to evaluate the effectiveness of PRP in the treatment of the arthritic knee. It is still too soon to determine if this form of treatment will be any more effective than current treatment methods.
– Fractures
PRP has been used in a very limited way to speed the healing of broken bones. So far, it has shown no significant benefit.Treatment with platelet-rich plasma holds great promise. Currently, however, the research studies to back up the claims in the media are lacking. Although PRP does appear to be effective in the treatment of chronic tendon injuries about the elbow, the medical community needs more scientific evidence before it can determine whether PRP therapy is truly effective in other conditions.Even though the success of PRP therapy is still questionable, the risks associated with it are minimal: There may be increased pain at the injection site, but the incidence of other problems — infection, tissue damage, nerve injuries — appears to be no different from that associated with cortisone injections.

If you are considering treatment with PRP, be sure to check your eligibility with your health insurance carrier. Few insurance plans, including workers’ compensation plans, provide even partial reimbursement.

Platelet Rich Plasma (PRP) therapy holds Great Promise to heal the Soft Tissue, Chronic Tendon Injury, Knee Osteoarthritis, Sports Injury, Acute Ligament and Muscle Injury. Get your PRP done with us today. Call us at +65 97731458 to schedule for an appointment

Golfer Elbow (Medial Epicondylitis)

Stop your Elbow Pain today. Effective Treatment, Non Surgery. Discuss with our Elbow Specialist for the Diagnosis, Treatment and Prognosis of your Elbow Pain. Call us +65 97731458 to schedule for an appointment.

Medial Epicondylitis is inflammation at the point where the tendons of the forearm attach to the bony prominence of the inner elbow. As an example, this tendon can become strained in a golf swing, but many other repetitive motions can injure the tendon. Golfer’s elbow is characterized by local pain and tenderness over the inner elbow. The range of motion of the elbow is preserved because the inner joint of the elbow is not affected. Those activities which require twisting or straining the forearm tendon can elicit pain and worsen the condition.

What is Golfers Elbow?

These problems, tennis elbow and golfer’s elbow, are both forms of tendonitis. Tendons are the ends of muscles that attach to bone. Because of the force of the muscle, the points of insertion of the tendon on the bone are often pointed prominences. The medical names of Tennis Elbow (lateral epicondylitis) and Golfer’s Elbow (medial epicondylitis) come from the names of these bony prominences where the tendons insert, and where the inflammation causes the pain. The pain of golfer’s elbow is usually at the elbow joint on the inside of the arm; a shooting sensation down the forearm is also common while gripping objects.

What causes golfers elbow?

The mechanism of this injury can vary from a single violent action to, more commonly, repetitive stress injury where an action is performed repeatedly and pain gradually develops. No one is immune from these injuries, but they are most common at the beginning of the golf season, or when the offending activity is increased in intensity or duration. Golf is one common cause of these symptoms, but many other sport- and work-related activities can cause the same problem. Another common cause of this injury is with weekend carpenters who use hand tools on occasion.

What are the treatment options available for golfers elbow?

Treatment includes Medicines and Anti-inflammatory injection for mild cases, Shockwave Therapy will be one of the effective non-invasive treatment, PRP and Surgery intervention will be the last source of treatment if all the conservative treatments do not respond well.

Stop your Elbow Pain today. Effective Treatment, Non Surgery. Discuss with our Elbow Specialist for the Diagnosis, Treatment and Prognosis of your Elbow Pain. Call us +65 97731458 to schedule for an appointment.

Elbow Arthritis

Definition of Arthritis of the Elbow

Inflammation of the elbow joint (arthritis) can occur as a result of many systemic forms of arthritis, including rheumatoid arthritis, osteoarthritis, gouty arthritis, psoriatic arthritis, ankylosing spondylitis, and reactive arthritis (formerly called Reiter’s disease). Generally, they are associated with signs of inflammation of the elbow joint, including heat, warmth, swelling, pain, tenderness, and decreased range of motion. Range of motion of the elbow is decreased with arthritis of the elbow because the swollen joint impedes the range of motion.

Causes of Elbow Arthritis

Arthritis involves the breakdown of cartilage. Cartilage normally protects the joint, allowing for smooth movement. Cartilage also absorbs shock when pressure is placed on the joint, like when you walk. Without the usual amount of cartilage, the bones rub together, causing pain, swelling (inflammation), and stiffness.

You may have joint inflammation for a variety of reasons, including:

  • An autoimmune disease (the body attacks itself because the immune system believes a body part is foreign)
  • Broken bone
  • General “wear and tear” on joints
  • Infection (usually caused by bacteria or viruses)

Often, the inflammation goes away after the injury has healed, the disease is treated, or the infection has been cleared.

With some injuries and diseases, the inflammation does not go away or destruction results in long-term pain and deformity. When this happens, you have chronic arthritis. Osteoarthritis is the most common type and is more likely to occur as you age. You may feel it in any of your joints, but most commonly in your hips, knees or fingers. Risk factors for osteoarthritis include:

  • Being overweight
  • Previously injuring the affected joint
  • Using the affected joint in a repetitive action that puts stress on the joint (baseball players, ballet dancers, and construction workers are all at risk)

Arthritis can occur in men and women of all ages. About 37 million people in America have arthritis of some kind, which is almost 1 out of every 7 people.

Symptoms of Elbow Arthritis

If you have arthritis, you may experience:

  • Joint pain
  • Joint swelling
  • Reduced ability to move the joint
  • Redness of the skin around a joint
  • Stiffness, especially in the morning
  • Warmth around a joint

Exams and Tests of Elbow Arthritis

First, our doctor will take a detailed medical history to see if arthritis or another musculoskeletal problem is the likely cause of your symptoms.

Next, a thorough physical examination may show that fluid is collecting in the joint. (This is called an “effusion.”) The joint may be tender when it is gently pressed, and may be warm and red (especially in infectious arthritis and autoimmune arthritis). It may be painful or difficult to rotate the joints in some directions. This is known as “limited range-of-motion.”

In some autoimmune forms of arthritis, the joints may become deformed if the disease is not treated. Such joint deformities are the hallmarks of severe, untreated rheumatoid arthritis.

Tests vary depending on the suspected cause. They often include blood tests and joint x-rays. To check for infection and other causes of arthritis (like gout caused by crystals), joint fluid is removed from the joint with a needle and examined under a microscope. See the specific types of arthritis for further information.

Treatment of Elbow Arthritis

Treatment of arthritis depends on the cause, which joints are affected, the severity, and how the condition affects your daily activities. Your age and occupation will also be taken into consideration when your doctor works with you to create a treatment plan.

If possible, treatment will focus on eliminating the cause of the arthritis. However, the cause is NOT necessarily curable, as with osteoarthritis and rheumatoid arthritis. Treatment, therefore, aims at reducing your pain and discomfort and preventing further disability.

It is possible to greatly improve your symptoms from osteoarthritis and other long-term types of arthritis without medications. In fact, making lifestyle changes without medications is preferable for osteoarthritis and other forms of joint inflammation. If needed, medications should be used in addition to lifestyle changes.

Exercise for arthritis is necessary to maintain healthy joints, relieve stiffness, reduce pain and fatigue, and improve muscle and bone strength. Your exercise program should be tailored to you as an individual. Work with a physical therapist to design an individualized program, which should include:

  • Low-impact aerobic activity (also called endurance exercise)
  • Range of motion exercises for flexibility
  • Strength training for muscle tone

A physical therapist can apply heat and cold treatments as needed and fit you for splints or orthotic (straightening) devices to support and align joints. This may be particularly necessary for rheumatoid arthritis. Your physical therapist may also consider water therapy, ice massage, or transcutaneous nerve stimulation.

Rest is just as important as exercise. Sleeping 8 to 10 hours per night and taking naps during the day can help you recover from a flare-up more quickly and may even help prevent exacerbations. You should also:

  • Avoid holding one position for too long.
  • Avoid positions or movements that place extra stress on your affected joints.
  • Modify your home to make activities easier. For example, have grab bars in the shower, the tub, and near the toilet.
  • Reduce stress, which can aggravate your symptoms. Try meditation or guided imagery. And talk to your physical therapist about yoga or tai chi.

Other measures to try include:

  • Apply capsaicin cream (derived from hot chili peppers) to the skin over your painful joints. You may feel improvement after applying the cream for 3-7 days.
  • Eat a diet rich in vitamins and minerals, especially antioxidants like vitamin E. These are found in fruits and vegetables. Get selenium from Brewer’s yeast, wheat germ, garlic, whole grains, sunflower seeds, and Brazil nuts. Get omega-3 fatty acids from cold water fish (like salmon, mackerel, and herring), flaxseed, rapeseed (canola) oil, soybeans, soybean oil, pumpkin seeds, and walnuts.
  • Taking glucosamine and chondroitin — these form the building blocks of cartilage, the substance that lines joints. These supplements are available at health food stores or supermarkets. While some studies show such supplements may reduce osteoarthritis symptoms, others show no benefit. However, since these products are regarded as safe, they are reasonable to try and many patients find their symptoms improve.
  • Lose weight, if you are overweight. Weight loss can greatly improve joint pain in the legs and feet.

SURGERY AND OTHER APPROACHES FOR ELBOW ARTHRITIS

In some cases, surgery to rebuild the joint (arthroplasty) or to replace the joint (such as a total knee joint replacement) may help maintain a more normal lifestyle. The decision to perform joint replacement surgery is normally made when other alternatives, such as lifestyle changes and medications, are no longer effective.

Normal joints contain a lubricant called synovial fluid. In joints with arthritis, this fluid is not produced in adequate amounts. In some cases, a doctor may inject the arthritic joint with a manmade version of joint fluid. The synthetic fluid may postpone the need for surgery at least temporarily and improve the quality of life for persons with arthritis.

When to Contact a Medical Professional

Call our doctor if:

  • Your joint pain persists beyond 3 days.
  • You have severe unexplained joint pain.
  • The affected joint is significantly swollen.
  • You have a hard time moving the joint.
  • Your skin around the joint is red or hot to the touch.
  • You have a fever or have lost weight unintentionally.

Prevention of Elbow Arthritis

If arthritis is diagnosed and treated early, you can prevent joint damage. Find out if you have a family history of arthritis and share this information with your doctor, even if you have no joint symptoms.

Osteoarthritis may be more likely to develop if you abuse your joints (injure them many times or over-use them while injured). Take care not to overwork a damaged or sore joint. Similarly, avoid excessive repetitive motions.

Cubital Tunnel Syndrome

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Definition of Cubital Tunnel Syndrome:

Nerve compression syndromes cause symptoms including pain, numbness, and weakness. Nerves can become pinched for a variety of reasons. Most people are familiar with carpal tunnel syndrome, a condition where the median nerve is pinched in the wrist. In the case of cubital tunnel syndrome, one of the other nerves of the upper extremity, the ulnar nerve, is pinched as it passes behind the elbow. This is the same nerve that causes the tingling sensation of hitting your “funny bone.”

Hitting your funny bone is actually a sensation caused by irritating the ulnar nerve behind the elbow. When struck, this causes a shooting sensation and tingling in the small and ring fingers. The ulnar nerve transmits signals to your brain about sensations in these fingers–that’s why the fingers tingle when you hit the nerve in your elbow.

Symptoms of Cubital Tunnel Syndrome
In patients with cubital tunnel syndrome, the ulnar nerve is pinched in one of several locations in the back of the elbow. Common symptoms of cubital tunnel syndrome include:

  • Pain, tingling and numbness in the small and ring fingers
  • Weakness of the muscles in the hand

These weakened muscles, called the intrinsic muscles of the hand, help with finger movements. Patients with more severe symptoms of cubital tunnel syndrome may experience a tendency to drop objects or have difficulty with fine movements of the fingers.

Diagnosis of Cubital Tunnel Syndrome

The diagnosis of cubital tunnel syndrome is made after a thorough history and examination. X-rays or other tests may be ordered if there is a concern of something abnormal pressing on the nerve. Nerve tests, called EMGs, can help to determine the extent of nerve compression, and the location of the nerve compression.

Treatment of Cubital Tunnel Syndrome

Treatment of cubital tunnel syndrome usually begins with some simple steps. Many cases of cubital tunnel syndrome will resolve with a few simple treatments:

  • Anti-inflammatory medications
  • Splinting the elbow, especially at night
  • Padding the elbow for work activities

If these simple treatments fail, surgery may be necessary. Surgery is performed to remove the pressure from the ulnar nerve. Because the nerve can be pinched at one of several locations behind the elbow it is important to know specifically where the nerve is pinched, or to release pressure from all f the possible areas of compression. In some patients, treatment consists of moving the nerve to the front of the elbow, so the nerve is under less tension when the elbow is bent; this is called an ulnar nerve transposition.

Depending on the severity of nerve damage, symptoms may resolve very quickly or they may never entirely resolve. In the most severe cases of cubital tunnel syndrome, some of the symptoms may persist despite surgical treatment.

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Tennis Elbow (Lateral Epicondylitis)

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What is Tennis Elbow or Lateral Humeral Epicondylitis?

Lateral epicondylitis, commonly known as tennis elbow, is not limited to tennis players. The backhand swing in tenis can strain the muscles and tendons of the elbow in a way that leads of repetitive activities can also lead to tennis elbow. But many other types of repetitive activities can also lead to tennis elbow: painting with a brush or roller, running a chain saw and using many types of hand tools. Any activities that repeatedly stress the same forearm muscles can cause symptoms of tennis elbow.

What parts of the elbow are affected?

Tennis elbow causes pain that starts on the outside bump of the elbow, the lateral epicondyle. The forearm muscles that bend the wrist back (the extensors) attach on the lateral epicondyle and are connected by a single tendon. Tendons connect muscles to bone.

Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other.

Because the collagen strands in tendons are lined up, tendons have high tensile strength. This means they can withstand high forces that pull on both ends of the tendon. When muscles work, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.

When you bend your wrist back or grip with your hand, the wrist extensor muscles contract. The contracting muscles pull on the extensor tendon. The forces that pull on these tendons can build when you grip things, hit a tennis ball in a backhand swing in tennis, or do other similar actions.

What are the causes of Tennis Elbow or Lateral Humeral Epicondylitis?

Overuse of the muscles and tendons of the forearm and elbow are the most common reason people develop tennis elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily high level sports competition. Hammering nails, picking up heavy buckets, or pruning shrubs can all cause the pain of tennis elbow.

In an acute injury, the body undergoes an inflammatory response. Special inflammatory cells make their way to the injured tissue to help them heal. Conditions that involve inflammation are indicated by -itis on the end of the word. For example, inflammation in a tendon is called tendonitis. Inflammation around the lateral epicondyle is called lateral epicondylitis.

However, tennis elbow often does not involve inflammation. Rather, the problem is within the cells of the tendon. Doctors call this condition tendinosis. In tendinosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers.

Instead of inflammatory cells, the body produces a type of cells called fibroblasts. When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue.

No one really knows exactly what causes tendinosis. Some orthopaedics think that the forearm tendon develops small tears with too much activity. The tears try to heal, but constant strain and overuse keep re-injuring the tendon. After a while, the tendons stop trying to heal. The scar tissue never has a chance to fully heal, leaving the injured areas weakened and painful.

What does Tennis Elbow feel like?

The main symptom of tennis elbow is tenderness and pain that starts at the lateral epicondyle of the elbow. The pain may spread down the forearm. It may go as far as the back of the middle and ring fingers. The forearm muscles may also feel tight and sore.

The pain usually gets worse when you bend your wrist backward, turn your palm upward, or hold something with a stiff wrist or straightened elbow. Just reaching into the refrigerator to get a carton of milk can cause pain. Sometimes the elbow feels stiff and won’t straighten out completely.

How is Tennis Elbow or Lateral Humeral Epicondylitis diagnosed?

Our specialist will first take a detailed medical history. You will need to answer questions about your pain, how your pain affects you, your regular activities, and past injuries to your elbow.

The physical exam is often most helpful in diagnosing tennis elbow. Our specialist may position your wrist and arm so you feel a stretch on the forearm muscles and tendons. This is usually painful with tennis elbow. There are also other tests for wrist and forearm strength that can be used to detect tennis elbow.

You may need to get X-rays of your elbow. The X-rays mostly help our specialist rule out other problems with the elbow joint. The X-ray may show if there are calcium deposits on the lateral epicondyle at the connection of the extensor tendon.

Tennis elbow symptoms are very similar to a condition called radial tunnel syndrome. This condition is caused by pressure on the radial nerve as it crosses the elbow. If your pain does not respond to treatments for tennis elbow, our specialist may suggest tests to rule out problems with the radial nerve.

When the diagnosis is not clear, our specialist may order other special tests. A magnetic resonance imaging (MRI) scan is a special imaging test that uses magnetic waves to create pictures of the elbow in slices. The MRI scan shows tendons as well as bones.

Ultrasound tests use high frequency sound waves to generate an image of the tissues below the skin. As the small ultrasound device is rubbed over the sore area, an image appears on a screen. This type of test can sometimes show problems with collagen degeneration.

What are the treatments of Tennis Elbow or Lateral Humeral Epicondylitis?

Nonsurgical Treatment:

The key to nonsurgical treatment is to keep the collagen from breaking down further. The goal is to help the tendon heal.

If the problem is caused by acute inflammation, anti-inflammatory medications  may give you some relief. If inflammation doesn’t go away, our specialist may inject the elbow with anti-inflammatory medication.

Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. This is to help generate the healing process of the tendon.

Surgical Treatment:

Sometimes nonsurgical treatment fails to stop the pain or help patients regain use of the elbow. In these cases, surgery may be necessary.

– Tendon Debridement

When problems are caused by tendinosis, surgeons may choose to take out (debride) only the affected tissues within the tendon. In these cases, the surgeon cleans up the tendon, removing only the damaged tissue.

– Tendon Release

A commonly used surgery for tennis elbow is called a lateral epicondyle release. This surgery takes tension off the extensor tendon. The surgeon begins by making an incision along the arm over the lateral epicondyle. Soft tissues are gently moved aside so the surgeon can see the point where the extensor tendon attached on the lateral epicondyle.

The extensor tendon is then cut where it connects to the lateral epicondyle. The surgeon splits the tendon and takes out any extra scar tissue. Any bone spurs found on the lateral epicondyle are removed. (Bone spurs are pointed bumps that can grow on the surface of the bones). Some surgeons suture the loose end of the tendon to the nearby fascia tissue. (Fascia tissue covers the muscles and organs throughout your body). The skin is then stitched together.

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Shoulder Slap Lesion

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SLAP tear is an injury to a part of the shoulder joint called the labrum. The shoulder joint is a ball and socket joint, similar to the hip; however, the socket of the shoulder joint is extremely shallow, and thus inherently unstable. To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within.

A specific type of labral tear is called a SLAP tear; this stands for Superior Labrum from Anterior to Posterior. The SLAP tear occurs at the point where the tendon of the biceps muscle inserts on the labrum.

How does a SLAP tear occur?
Common reasons for a SLAP tear include:

  • Fall onto an outstretched hand
  • Repetitive overhead actions (throwing)
  • Lifting a heavy object

The area of the labrum where the SLAP tear occurs is susceptible to injury because it is an area of relatively poor vascularity. Other parts of the labrum often heal more easily because the blood supply delivers a healing capacity to the area of the tear. In the area of SLAP tears this is not the case, and chronic shoulder pain can result.

What are the symptoms of a SLAP tear?
Typical symptoms of a SLAP tear include a catching sensation and pain with shoulder movements, most often overhead activities such as throwing. Patients usually complain of pain deep within the shoulder or in the back of the shoulder joint. It is often hard to pinpoint symptoms, unless the biceps tendon is also involved. In cases of SLAP tears with associated biceps tendonitis, patients may complain of pain over the front of the shoulder.

How is a SLAP tear diagnosed?
There are several tests a skilled examiner can perform to detect for SLAP tears. These tests are part of a shoulder physical examination. In addition, careful questioning of the patient can help the examiner identify symptoms consistent with a SLAP tear.

Diagnosis of a SLAP tear can be difficult, as these injuries may not show up well on MRI scans. SLAP tears tend to be seen best on MRI when the study is performed with an injection of contrast. A contrast MRI is performed by injecting a fluid called gadolinium into the shoulder; the gadolinium helps to highlight tears of normal structures, including SLAP tears. Sometimes the diagnosis of a SLAP tear is made at the time of surgery.

Most patients with SLAP tears will respond to conservative (meaning non-surgical) treatments. Any patient with a SLAP tear will be advised to rest after the injury to allow the injured tissue to cool down. A period of rest will allow inflammation to subside and may help to alleviate symptoms.

Other treatments that are often used in cases of a SLAP tear include:

  • Physical therapy
  • Anti-inflammatory medication
  • Injections

What if these treatments do not work?
In patients who have continued symptoms despite these treatments, arthroscopic surgery of the shoulder may be recommended. There are several specific surgical procedures that may be performed, and it is important to understand that SLAP tears often occur in conjunction with other shoulder problems such as rotator cuff tears, and even shoulder arthritis. In these cases, surgical treatment will have to take into account these factors.

The primary treatment options for the SLAP tear are:

  • Debridement of the SLAP tear
    When a SLAP tear is debrided, the torn portion of the labrum is shaved away to leave a smooth edge. This option is only suitable for minor tears that do not involve the biceps tendon.
  • SLAP repair
    A SLAP repair is an arthroscopic procedure that uses sutures with anchors attached to resecure the torn labrum down to the shoulder socket. A SLAP repair is best suited to patients with an otherwise healthy shoulder who want to remain athletically active.

A SLAP repair is a procedure performed for treatment of a SLAP tear. Surgical treatment of a SLAP tear is considered for patients who do not respond to more conservative treatments. In these patients who have a symptomatic SLAP tear, surgical treatment is an option.

As stated previously, several surgical options are available. These include SLAP debridement, SLAP repair, and biceps tenodesis. A SLAP debridement simply removed any excess or damaged tissue that causes symptoms of catching and pain in the shoulder.

When is a SLAP repair an appropriate treatment?
A SLAP repair is considered for treatment when the attachment of the labrum (the so-called biceps anchor) is unstable. In these cases, debridement would not be adequate to alleviate the symptoms of the SLAP tear.

How is a SLAP repair performed?
A SLAP repair is performed arthroscopically using sutures to reattach the torn labrum back to the bone. The steps of a SLAP repair are:

1. The SLAP tear is identified and excess tissue is removed.

2. A small hole is drilled into the bone where the labrum has torn off (the SLAP tear).

3. An anchor is placed into this hole; attached to the anchor is a strong suture.

4. The suture is used to tie the torn labrum snuggly against the bone.

What are the advantages of a SLAP repair?

  • A SLAP repair restores the normal anatomy of the shoulder by reattaching the labrum in its normal position.
  • Once healed, the SLAP repair allows normal function of the previously damaged labrum and biceps attachment.

What are the advantages of other treatments such as debridement or tenodesis?

  • The rehabilitation is often not as restrictive as is the case with a SLAP repair.
  • The results of surgery are usually more predictable, as healing of a SLAP repair is not as reliable.

What is the rehab after a SLAP repair?
Rehabilitation varies depending on factors such as the strength of the SLAP repair, and the preference of the surgeon. Most often, a period of time of restricted motion is maintained for about six weeks following a SLAP repair. During this first phase of rehabilitation, some passive motion is allowed to prevent shoulder stiffness. In the first phase, the torn labrum is healing into its proper position.

Once healed, patients enter the second phase of rehabilitation and can begin more motion at about six weeks. Physical therapy continues to help maintain motion and regain strength of the shoulder. The final phase of rehabilitation involves more active strengthening of the muscles that surround the shoulder joint, and full recovery is expected between 3 to 4 months.

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Shoulder Dislocation / Instability

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Shoulder instability is a problem that occurs when the structures that surround the glenohumeral (shoulder) joint do not work to maintain the ball within its socket. If the joint is too loose, is may slide partially out of place, a condition called shoulder subluxation. If the joint comes completely out of place, this is called a shoulder dislocation. Patients with shoulder instability often complain of an uncomfortable sensation that their shoulder may be about to slide out of place–this is what physicians call apprehension.
Shoulder instability tends to occur in three groups of people:

  • Prior Shoulder Dislocators. Patients who have sustained a prior shoulder dislocation often develop chronic instability. In these patients, the ligaments that support the shoulder are torn when the dislocation occurs. If these ligaments heal too loosely, then the shoulder will be prone to repeat dislocation and episodes of instability. When younger patients (less than about 35 years old) sustain a traumatic dislocation, shoulder instability will follow in about 80% of patients.
  • Young Athletes. Athletes who compete in sports that involve overhead activities may have a loose shoulder or multidirectional instability (MDI). These athletes, such as volleyball players, swimmers, and baseball pitchers, stretch out the shoulder capsule and ligaments, and may develop chronic shoulder instability. While they may not completely dislocate the joint, the apprehension, or feeling of being about to dislocate, may prevent their ability to play these sports.
  • “Double-Jointed” Patients. Patients with some connective tissue disorders may have loose shoulder joints. In patients who have a condition that causes joint laxity, or double-jointedness, their joints may be too loose throughout their body. This can lead to shoulder instability and even dislocations.

What is the treatment of shoulder instability?
Treatment of shoulder instability depends on several factors, and almost always begins with physical therapy and rehab. If patients complain of a feeling that their shoulder is loose or about to dislocate, physical therapy with specific strengthening exercises will often help maintain the shoulder in proper position. Shoulder strengthening is most likely to help the second group of patients athletes with multi-directional shoulder instability. Other treatments sometimes used to treat shoulder instability include injections and anti-inflammatory medications.

Will I need surgery for shoulder instability?
If therapy fails, there are surgical options that can be considered. Depending on the cause of the instability, the surgical treatments may be quite different.

If the cause of the shoulder instability is a loose shoulder joint capsule, then a procedure to tighten the capsule of the shoulder may be considered. This can be done with an arthroscope in a procedure called athermal capsular shrinkage. In this surgery, a heated probe shrinks the shoulder capsule to tighten the tissue. The more standard method of this procedure is called an open capsular shift. In this surgery, the shoulder joint is opened through a larger incision, and the capsule is tightened with sutures. The advantage of the open capsular shift is that the results are more predictable. The advantage of the arthroscopic procedure is that the recovery is faster and the incision is smaller. Sometimes a particular problem is better suited to one procedure or the other, discuss this with our surgeon.

If the problem is due to a tearing of the ligaments around the shoulder, called the labrum, then a procedure called a Bankart repair can be performed to fix this ligament. A Bankart repair can also be done either through an incision or an arthroscope. Again, the results of the open procedure are more predictable (more patients get better), but the arthroscopic procedure does not leave as large an incision.

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Shoulder Arthritis

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Osteoarthritis is the most common type of shoulder arthritis. Also called wear-and-tear arthritis or degenerative joint disease, osteoarthritis is characterized by progressive wearing away of the cartilage of the joint. As the protective cartilage surface of the joint is worn away by shoulder arthritis, bare bone is exposed within the shoulder.

The other common type of shoulder arthritis is rheumatoid arthritis. Rheumatoid arthritis is a systemic condition that causes inflammation of the lining of the joints. This inflammation can, over time, invade and destroy the cartilage and bone.

Who develops Shoulder Arthritis?

Shoulder arthritis typically affects patients over 50 years of age. It is more common in patients who have a history of prior shoulder injury. There is also a genetic predisposition of this condition, meaning shoulder arthritis tends to run in families.

What are the common symptoms of Shoulder Arthritis?

Shoulder arthritis symptoms tend to progress as the condition worsens. What is interesting about shoulder arthritis is that symptoms do not always progress steadily with time. Often patients report good months and bad months, or symptom changes associated with weather changes. This is important to understand because comparing the symptoms of arthritis on one particular day may not accurately represent the overall progression of the condition.

The most common symptoms of shoulder arthritis are:

  • Shoulder Pain with activities
  • Limited range of motion
  • Stiffness of the shoulder
  • Swelling of the joint
  • Tenderness around the joint
  • A feeling of grinding or catching within the joint

Evaluation of a patient with shoulder arthritis should begin with a physical examination and x-rays. These can serve as a baseline to evaluate later examinations and determine progression of the condition.

What is the treatment for Shoulder Arthritis?

Treatment of shoulder arthritis should begin with the most basic steps, and progress to the more involved, possibly including surgery. Not all treatments are appropriate in every patient, and you should have a discussion with your doctor to determine which treatments are appropriate for your shoulder arthritis.

  • Shoulder Exercises
  • Physical Therapy
  • Anti-Inflammatory Medicines
  • Anti-Inflammatory Injections
  • Joint Supplement (Glucosamine)
  • Shoulder Arthroscopy
  • Shoulder Replacement Surgery

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Rotator Cuff Tear

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The rotator cuff is made up of four muscles that help move and stabilize the shoulder joint. Damage to any one of the four muscles or their ligaments that attach the muscle to bone can occur because of acute injury, chronic overuse, or gradual aging. This can cause significant pain and disability with range of motion or use of the shoulder joint.

The shoulder is a ball-socket joint that allows the arm to move in many directions. It is made up of the humeral head (the upper end of the bone of the upper arm) fitting into the glenoid fossa of the scapula (shoulder blade). The humeral head is kept in place by the joint capsule and labrum, thick bands of cartilage that form an elongated cone where the humeral head fits. The rotator cuff muscles are the dynamic stabilizers and movers of the shoulder joint and adjust the position of the humeral head and scapula during shoulder movement.

When the rotator cuff is damaged, a variety of issues arise:

  • Shoulder Pain and spasm limit the range of motion of the shoulder.
  • The muscles do not make the small adjustments within the joint to allow the humeral head to move smoothly.
  • Fluid accumulation within the joint due to inflammation limits movement.
  • Arthritis and calcium deposits that form over time limit range of motion.

The severity of injury may range from a mild strain and inflammation of the muscle or tendon, that will lead to no permanent damage, to a partial or complete tear of the muscle that might require surgery for repair.

What are the causes of Rotator Cuff Injury?

Injuries to muscle-tendon units are called strains and are classified by the amount of damage to the muscle or tendon fibers. Grade I strains involve stretching of the fibers without any tears. Grade II injuries involve partial muscle or tendon tearing, and grade III injuries are defined as a complete tear of a muscle or tendon.

The muscles and tendons in the rotator cuff group may be damaged in a variety of ways. Damage can occur from an acute injury (for example from a fall or accident), from chronic overuse (like throwing a ball or lifting), or from gradual degeneration of the muscle and tendon that can occur with aging.

  • Acute rotator cuff tear
  • This injury can develop from sudden powerful raising of the arm against resistance or in an attempt to cushion a fall (for example, heavy lifting or a fall on the shoulder).
  • The injury requires a significant amount of force if person is younger than 30 years of age.
  • Chronic tear
  • Found among people in occupations or sports requiring excessive overhead activity (examples, painters, baseball pitchers)
  • The chronic injuries may be a result of a previous acute injury that has caused a structural problem within the shoulder and affected the rotator cuff anatomy or function (for example, bone spurs that impinge upon a muscle or tendon causing inflammation).
  • Repetitive trauma to the muscle by everyday movement of the shoulder
  • Tendinitis
  • Degeneration (wearing out) of the muscles with age.
  • This usually occurs where the tendon attaches to bone. The area has poor blood supply and a mild injury may take a long time to heal and potentially lead to a secondary tear.

What are the symptoms of Rotator Cuff Injury?

Symptoms of a rotator cuff injury are due to the inflammation that accompanies the strain. This inflammation causes swelling, leading to the clinical picture of pain and decreased range of motion. Because the muscles and tendons of the rotator cuff are hidden well below skin level, it may be hard to feel the swelling that accompanies the injury, but that swelling within the small space that makes up the shoulder joint prevents the normal range of motion of the shoulder joint.

  • Acute rotator cuff tear
  • Symptoms can be a sudden tearing sensation followed by severe pain shooting from the upper shoulder area (both in front and in back) down the arm toward the elbow. There is decreased range of motion of the shoulder because of pain and muscle spasm.
  • Acute pain from bleeding and muscle spasm: This may resolve in a few days.
  • Large tears may cause the inability abduct the arm (raise it out to the side) due to significant pain and loss of muscle power.
  • Chronic rotator cuff tear
  • Pain usually is worse at night and may interfere with sleep.
  • Gradual weakness and decreased shoulder motion develop as the pain worsens.
  • Decrease in the ability to abduct the arm or move it out to the side. This allows the arm to be used for most activities but the affected person is unable to use the injured arm for activities that entail lifting the arm as high as or higher than the shoulder to the front or side.
  • Rotator cuff tendinitis
  • More common in women 35-50 years of age
  • Deep ache in the shoulder also felt on the outside upper arm over the deltoid muscle
  • Point tenderness may be appreciated over the area that is injured
  • Pain comes on gradually and becomes worse with lifting the arm to the side (abduction) or turning it inward (internal rotation)
  • May lead to a chronic tear: When a rotator cuff tendon becomes inflamed (tend=tendon +itis=inflammation), it runs the risk of losing its blood supply, causing some tendon fibers to die. This increases the risk that the tendon can fray and partially or completely tear.

What are the treatment options available for rotator cuff injury?

  • Anti-inflammatory medications like ibuprofen and naproxen may help reduce pain and swelling.
  • A sling may help support the arm rest the rotator cuff muscles. Long-term use of a sling is not advised, since it may cause significant stiffening of the shoulder joint.
  • Usually, acute rotator cuff injuries require more than one visit to the care provider and may also require referral to an orthopedic specialist for advice and care. Surgery may be considered within a few weeks, especially in younger, active patients, to return the shoulder to full function.

Indications for surgical treatment include the following:

  • Usually for patients younger than 60 years of age
  • Complete rotator cuff tears
  • Failure of conservative therapy (physical therapy, rest and anti-inflammatory medications) after six to eight weeks
  • Employment or sporting activity that requires constant shoulder use.

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What is Rotator Cuff Tendonitis?

Labral Tear (Labrum Tear)

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The shoulder joint is a ball and socket joint, similar to the hip; however, the socket of the shoulder joint is extremely shallow, and thus inherently unstable. This means that the bones of the shoulder are not held in place adequately, and therefore extra support is needed.

To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within. The labrum circles the shallow shoulder socket (the glenoid) to make the socket deeper. This cuff of cartilage makes the shoulder joint much more stable, and allows for a very wide range of movements (in fact, the range of movements your shoulder can make far exceeds any other joint in the body).

What is a labral tear?
The labrum is made of a thick tissue that is susceptible to injury with trauma to the shoulder joint. When a patient sustains a shoulder injury, it is possible that the patient has a labral tear. The labrum also becomes more brittle with age, and can fray and tear as part of the aging process.

What are the symptoms of a torn labrum?
Symptoms of a labral tear depend on where the tear is located, but may include:

  • An aching sensation in the shoulder joint
  • Catching of the shoulder with movement
  • Shoulder Pain with specific activities

In addition, some types of labral tears, specifically a Bankart lesion, can increase the potential for shoulder dislocations.

What are the common types of labral tears? 
The most common patterns of labral tears are:

  • SLAP Tears 
    A SLAP tear is a type of labral tear most commonly seen in overhead throwing athletes such as baseball players and tennis players. The torn labrum seen in a SLAP tear is at the top of the shoulder socket where the biceps tendon attaches to the shoulder.
  • Bankart Lesions 
    A Bankart lesion is a labral tear that occurs when a shoulder dislocates. When the shoulder comes out of joint, the labrum is torn, and makes the shoulder more susceptible to future dislocations.
  • Posterior Labral Tears 
    Posterior labral tears are less common, but sometimes seen in athletes in a condition called internal impingement. In this syndrome, the rotator cuff and labrum are pinched together in the back of the shoulder.

Symptoms of a labral tear depend on where the tear is located, but may include:

  • An aching sensation in the shoulder joint
  • Catching of the shoulder with movement
  • Pain with specific activities

What is the treatment for a torn labrum?
The treatment of a torn labrum depends on the type of tear that has occurred. Most labral tears do not require surgery; however, in patients who have persistent symptoms despite more conservative treatments, surgery may be necessary.

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Frozen Shoulder (Adhesive Capsulitis)

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Definition of frozen shoulder:

Frozen shoulder, or adhesive capsulitis, is a condition that causes restriction of motion in the shoulder joint. The cause of a frozen shoulder is not well understood, but it often occurs for no known reason. Frozen shoulder causes the capsule surrounding the shoulder joint to contract and form scar tissue.

What causes frozen shoulder?

Most often, frozen shoulder occurs with no associated injury or discernible cause. There are patients who develop a frozen shoulder after a traumatic injury to the shoulder, but this is not the usual cause. Some risk factors for developing a frozen shoulder include:
  • Age & Gender
    Frozen shoulder most commonly affects patients between the ages of 40 to 60 years old, and it is twice as common in women than in men.
  • Endocrine Disorders
    Patients with diabetes are at particular risk for developing a frozen shoulder. Other endocrine abnormalities, such as thyroid problems, can also lead to this condition.
  • Shoulder Trauma or Surgery
    Patients who sustain a shoulder injury, or undergo surgery on the shoulder can develop a frozen shoulder joint. When injury or surgery is followed by prolonged joint immobilization, the risk of developing a frozen shoulder is highest.
  • Other Systemic Conditions
    Several systemic conditions such as heart disease and Parkinson’s disease have also been associated with an increased risk for developing a frozen shoulder.

What happens with a frozen shoulder?

No one really understands why some people develop a frozen shoulder. For some reason, the shoulder joint becomes stiff and scarred. The shoulder joint is a ball and socket joint. The ball is the top of the arm bone (the humeral head), and the socket is part of the shoulder blade (the glenoid). Surrounding this ball-and-socket joint is a capsule of tissue that envelops the joint.
Normally, the shoulder joint allows more motion than any other joint in the body. When a patient develops a frozen shoulder, the capsule that surrounds the shoulder joint becomes contracted. The patients form bands of scar tissue called adhesions. The contraction of the capsule and the formation of the adhesions cause the frozen shoulder to become stiff and cause movement to become painful.
A frozen shoulder causes a typical set of symptoms that can be identified by your doctor. The most important finding is restricted movement. Other shoulder conditions can cause difficulty with movement of the shoulder, such as a rotator cuff tear; therefore it is important to have an examiner familiar with this condition for a proper diagnosis.

What are the typical symptoms of frozen shoulder?

  • Shoulder pain; usually a dull, aching pain
  • Limited movement of the shoulder
  • Difficulty with activities such as brushing hair, putting on shirts/bras
  • Pain when trying to sleep on the affected shoulder

What are the stages of frozen shoulder?

  • Painful/Freezing Stage
    This is the most painful stage of a frozen shoulder. Motion is restricted, but the shoulder is not as stiff as the frozen stage. This painful stage typically lasts 6-12 weeks.
  • Frozen Stage
    During the frozen stage, the pain usually eases up, but the stiffness worsens. The frozen stage can last 4-6 months.
  • Thawing Stage
    The thawing stage is gradual, and motion steadily improves over a lengthy period of time. The thawing stage can last more than a year.

What test are needed to diagnose frozen shoulder?

Most often, a frozen shoulder can be diagnosed on examination, and no special tests are needed. An x-ray is usually obtained to ensure the shoulder joint appears normal, and there is not evidence of traumatic injury or arthritic changes to the joint. An MRI is sometimes performed if the diagnosis is in question, but this test is better at looking for other problems, rather than looking for frozen shoulder. If an MRI is done, it is best performed with an injection of contrast fluid into the shoulder joint prior to the MRI. This will help show if the capsule of the shoulder is scarred down, as would be expected in patients with a frozen shoulder.

What are the treatment options available for frozen shoulder?

Frozen shoulder treatment primarily consists of pain relief and physical therapy. Most patients find relief with these simple steps, although the entire treatment process can take several months or longer.
  • Exercises and Stretching
    Stretching exercises for frozen shoulder serves two functions:

    • First, to increase the motion in the joint
    • Second, to minimize the loss of muscle on the affected arm (muscle atrophy)
    The importance of stretching and exercises cannot be overemphasized as these are the key to successful frozen shoulder treatment. Patients cannot expect to have successful frozen shoulder treatment if they perform exercises only when working with a therapist. These exercises and stretches must be performed several times daily.
  • Moist Heat
    Applications of moist heat to the shoulder can help to loosen the joint and provide relief of pain. Patients can apply moist heat to the shoulder, then perform their stretching exercises–this should be done at least three times daily. Moist heat can be applied by using a hot-soaked washcloth on the joint for 10 minutes before stretching.
  • Physical Therapy
    Physical therapists can help a patient develop a stretching and exercise program, and also incorporate ultrasound, ice, heat, and other modalities into the rehabilitation for frozen shoulder. As said previously, it is important that patients perform their stretches and exercise several times daily–not only when working with the therapist.
  • Anti-inflammatory Medications
    Anti-inflammatory medications have not been shown to significantly alter the course of a frozen shoulder, but these medications can be helpful in offering relief from the painful symptoms.
  • Anti-Inflammatory Injections
    Anti-Inflammatory  injections are also commonly used to decrease the inflammation in the frozen shoulder joint. This can help to decrease pain, and in turn allow for more stretching and physical therapy.

Will i need surgery for frozen shoulder?

If the above treatments do not resolve the frozen shoulder, occasionally a patient will need to have surgery. If this is the case, the surgeon may perform a manipulation under anesthesia. A manipulation is performed with the patient sedated under anesthesia, and the doctor moves the arm to break up adhesions caused by frozen shoulder. There is no actual surgery involved, meaning incisions are not made when a manipulation is performed. Manipulation under Anaesthesia has very good result in treating frozen shoulder to whom that priorly only diagnosed with Frozen Shoulder without other shoulder problem. This procedure is very simple to do and only need 30 minutes to perform. This procedure is usually to be done under daycase. Patient will experience the improvement almost immediately after the procedure.

Alternatively, an arthroscope can be inserted into the joint to cut through adhesion. This procedure is called an arthroscopic capsular release. Surgical capsular release of a frozen shoulder is rarely necessary, but it is extremely useful in cases of frozen shoulder that do not respond to therapy and rehab. If surgery is performed, immediate physical therapy following the capsular release is of utmost importance.

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Calcific Tendonitis

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What is Calcific Tendonitis?

Calcific tendonitis is a condition that causes the formation of a small, usually about 1-2 centimeter size, calcium deposit within the tendons of the rotator cuff. These deposits are usually found in patients at least 30-40 years old, and have a higher incidence in diabetics. The calcium deposits are not always painful, and even when painful they will often spontaneously resolve after a period of 1-4 weeks.

What is the causes of Calcific Tendontis?

The cause of calcium deposits within the rotator cuff tendon is not entirely understood. Different ideas have been suggested, including blood supply and aging of the tendon, but the evidence to support these conclusions is not clear.

How does Calcific Tendonitis Progress?

Calcific tendonitis usually progresses predictably, and almost always resolves eventually without surgery. The typical course is:

  • Precalcification Stage
    Patients usually do not have any symptoms in this stage. At this point in time, the site where the calcifications tend to develop undergo cellular changes that predispose the tissues to developing calcium deposits.
  • Calcific Stage
    During this stage, the calcium is excreted from cells and then coalesces into calcium deposits. When seen, the calcium looks chalky, it is not a solid piece of bone. Once the calcification has formed, a so-called resting phase begins, this is not a painful period and may last a varied length of time. After the resting phase, a resorptive phase begins–this is the most painful phase of calcific tendonitis. During this resorptive phase, the calcium deposit looks something like toothpaste.
  • Postcalcific Stage
    This is usually a painless stage as the calcium deposit disappears and is replaced by more normal appearing rotator cuff tendon.

What are the treatment options available for Calcific Tendonitis?

Patients usually seek treatment during the painful resorptive phase of the calcific stage, but some patients have the deposits found incidentally as part of their evaluation impingement syndrome.

Nonoperative treatment is nearly always the first line of treatment for calcific tendonitis. The treatment protocol is similar to the treatment for impingement syndrome of the shoulder. This includes:

  • Physical Therapy/Exercises
    Exercises and stretching can help prevent a stiff shoulder. One of the most difficult problems associated with calcific tendonitis is the development of a frozen shoulder because of pain. Exercises can help prevent this problem from occurring.
  • Anti-Inflammatory Medications
    Anti-inflammatory medications can help treat the pain associated with the calcific tendonitis. No studies have shown a significant change in the time course of symptoms with these medications, but patients certainly have lessened symptoms.

When is surgery necessary?

Surgery is recommended in the following situations:

  • When symptoms continue to progress despite treatment
  • When constant pain interferes with routine activities (dressing, combing hair)
  • When symptoms do not respond to conservative care

Available treatment options include needling and aspiration of the calcium deposit and excision of the calcium deposit.

Needling is a procedure that is done under sedation or general anesthesia. Our surgeon will direct a large needle into the calcium deposit and attempt to aspirate, or suck out, as much of the calcium deposit as possible. Injections of saline, novocaine, is then performed into the calcium deposit. Patients can resume activity shortly after the procedure.

Excision of the deposit is a larger procedure, but may be necessary, especially is cases of chronic calcific tendonitis. Either through a small incision or through the use of shoulder arthroscopy, the calcium deposit is identified and removed. Physical therapy is usually necessary after this procedure to help regain strength and motion in the affected shoulder.

Are other treatments available for Calcific Tendonitis?

Over the last decade, several reports have shown successful treatment of chronic calcific tendonitis with the use of shockwave therapy. Shockwave therapy is thought to work by inducing so-called ‘microtrauma’ and stimulates blood flow to the affected area. Most reports on this method of treatment of calcific tendonitis show guarded success–perhaps 50-70% of patients improving after one or two high-energy shockwave treatments.

This treatment of calcific tendonitis can be painful, and usually requires anesthesia in order for it to be tolerated by the patient. The good news is that there is a very low complication rate from shockwave therapy. Most patients will develop a hematoma (bruising) from the treatment, but otherwise there are very few complications.

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Biceps Tendon Rupture

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What is a biceps tendon rupture?

A biceps tendon rupture is an injury that occurs to the biceps tendon causing the attachment to separate from the bone. A normal biceps tendon is connected strongly to the bone. When the biceps tendon ruptures, this tendon is detached. Following a biceps tendon rupture, the muscle cannot pull on the bone, and certain movements may be weakened and painful.

There are two types of biceps tendon ruptures:

  • Proximal Biceps Tendon Ruptures
    A proximal biceps tendon rupture is an injury to the biceps tendon at the shoulder joint. This injury type is the most common type of biceps tendon injury. It is most common in patients over 60 years of age, and often causes minimal symptoms.
  • Distal Biceps Tendon Ruptures
    The distal biceps tendon is injured around the elbow joint. This is usually an injury that occurs with heavy lifting or sports in middle-aged men. Most patients with a distal biceps rupture will have surgery to repair the torn tendon.
  • Rupture of the proximal head of the biceps tendon involves one of two heads of the biceps tendon. This condition usually occurs in older individuals and is caused by degenerative changes within the biceps tendon leading to failure of the structure. Most patients have preceding shoulder pain consistent with impingement syndrome or a rotator cuff tear. The proximal biceps tendon rupture may then occur during a trivial activity, and some patients may experience some pain relief once the damaged tendon ruptures.The proximal biceps tendon can rupture in a younger patient with activities such as weight-lifting or throwing sports, but this is quite unusual.

What are the causes of Biceps Tendon Rupture?

Biceps ruptures generally occur in people who are between 40 and 60 years old. People in this age group who’ve had shoulder problems for a long time are at most risk. Often the biceps ruptures after a long history of shoulder pain from tendonitis (inflammation of the tendon) or problems with shoulder impingement. Shoulder impingement is a condition where the soft tissues between the ball of the upper arm and the top of the shoulder blade (acromion) get squeezed with arm motion.

Years of shoulder wear and tear begin to fray the biceps tendon. Eventually, the long head of the biceps weakens and becomes prone to tears or ruptures. Examination of the tissues within most torn or ruptured biceps tendons commonly shows signs of degeneration. Degeneration in a tendon causes a loss of the normal arrangement of the collagen fibers that join together to form the tendon. Some of the individual strands of the tendon become jumbled due to the degeneration, other fibers break, and the tendon loses strength.

A rupture of the biceps tendon can happen from a seemingly minor injury. When it happens for no apparent reason, the rupture is called nontraumatic.

Aging adults with rotator cuff tears also commonly have a biceps tendon rupture. When the rotator cuff is torn, the ball of the humerus is free to move too far up and forward in the shoulder socket and can impact the biceps tendon. The damage may begin to weaken the biceps tendon and cause it to eventually rupture.

What are the symptoms of a proximal biceps tendon rupture?
Usually patients will have sudden pain associated with an audible snap in the area of their shoulder. The pain is usually not significant, and, as mentioned previously, some patients may experience pain relief after the rupture. After the ruptured tendon retracts, patients may notice a bulge in their arm at the biceps muscle. This is the retracted muscle bunched up in the arm, and is sometime referred to as a “Popeye Muscle,” because the muscle is more pronounced than normal.

What is the treatment for a proximal biceps tendon rupture?
Patients usually do not notice any loss of arm or shoulder function following a proximal biceps tendon rupture. A slight bulge in the arm, and some twitching of the retracted muscle are usually the most significant symptoms. Surgical repair of the proximal biceps tendon is usually only considered in the case of a younger patient who is more active.

The reason there is little functional loss following a proximal biceps tendon rupture is that there are actually two tendinous attachments of the biceps at the shoulder joint (that is why the muscle is named “bi-ceps,” meaning two heads). When the rupture occurs at the distal biceps tendon at the elbow, where there is only one attachment, surgical repair is much more commonly needed.

If pain persists following a proximal biceps tendon rupture, other causes of shoulder pain should be considered. These include impingement syndrome (rotator cuff bursitis), rotator cuff tears, or fractures around the shoulder.

Rupture of the distal biceps tendon at the elbow joint is much less common and accounts for less than 5% of biceps tendon ruptures. This injury is also usually found in middle-aged patients, although not always. There is usually some degree of tendinosus, or degenerative changes within the tendon, that predisposes the patient to rupture of the tendon.

The significance of a distal biceps tendon rupture is that without surgical repair, patients who experience complete rupture of the distal biceps tendon will notice loss of strength at the elbow. The strength will affect both the ability to bend the elbow against resistance, and the ability to turn the forearm to the palm-up position against resistance (for example, turning a doorknob or screwdriver).

What are the symptoms of distal biceps tendon rupture?
Distal biceps tendon rupture is characterized by sudden pain over the front of the elbow after a forceful effort against a flexed elbow. Usually the patient will hear a snap and have pain where the tendon rupture occurs. Swelling and bruising around the elbow are also common symptoms of distal biceps tendon rupture.

What is the treatment of distal biceps tendon rupture?
Most patients will experience benefit if the biceps tendon is repaired surgically. If the tear is incomplete, or if the patient is very low-demand (not active), then surgery may not be needed. However, most patients who want more normal use of their arm will benefit from surgery to repair the ruptured tendon to the bone.

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Rotator Cuff Tendonitis (Bursitis)

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What is Rotator Cuff Tendonitis?

Rotator cuff tendonitis is an inflammation (irritation and swelling) of the tendons of the shoulder.

What are the causes of Rotator Cuff Tendonitis?

The shoulder joint is a ball and socket type joint where the top part of the arm bone (humerus) forms a joint with the shoulder blade (scapula). The rotator cuff holds the head of the humerus into the scapula.

Inflammation of the tendons of the shoulder muscles can occur in sports requiring the arm to be moved over the head repeatedly as in tennis, baseball (particularly pitching), swimming, and lifting weights over the head. Chronic inflammation or injury can cause the tendons of the rotator cuff to tear.

The risk factors are being over age 40 and participation in sports or exercise that involves repetitive arm motion over the head (such as baseball).

What are the symptoms of Rotator Cuff Tendonitis?

  • Shoulder Pain associated with arm movement
  • Pain in the shoulder at night, especially when lying on the affected shoulder
  • Weakness with raising the arm above the head, or pain with overhead activities.

How to diagnose Rotator Cuff Tendonitis?
A physical examination may reveal tenderness over the shoulder. Pain may occur when the shoulder is raised overhead. There is usually weakness of the shoulder when it is placed in certain positions.

X-rays may show a bone spur, while MRI may show inflammation in the rotator cuff. An MRI can show a tear in the rotator cuff.

What is the treatment for Rotator Cuff Tendonitis?
Treatment involves resting the shoulder and avoiding activities that cause pain. Ice packs applied to the shoulder and nonsteroidal anti-inflammatory drugs will help reduce inflammation and pain.

Physical therapy to strengthen the muscles of the rotator cuff should be started. If the pain persists or if therapy is not possible because of severe pain, a steroid injection may reduce pain and inflammation enough to allow effective therapy.

If the rotator cuff has had a complete tear, or if the symptoms persist despite conservative therapy, surgery may be necessary. Arthroscopic surgery can be used to repair some tears and remove bone spurs and inflamed tissue around the shoulder. Some large tears require open surgery to repair the torn tendon.

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Gouty Arthritis

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Gout is a rheumatoid form of arthritis that causes the inflammation, joint pain and swelling especially in the toe, knee and ankle, also reducing their mobility. Gout usually appears in midlife and primarily in males. It can be hereditary or the secondary to some other disease process.

What are the causes of Gout?
Gout is mainly caused by the clustering of uric acid crystals in the arteries, obstructing normal blood flow and causing inflammation. Uric acid is a residual product that is excreted from the body through urine during synthesis of purine – a substance that presents in fat meats, fish, some dairy products and vegetables. The level of uric acid can be found and measured in the blood.

What are the first signs of gout attacks?
In most cases, the first gout signs appear at the level of the big toe. The skin around the affected regions turns yellow, appears to be stretched and bruised. The regions affected by gout become very sensitive. It even causes the sufferers can’t tolerate clothing or shoes. Gout attacks in the region of the big toe are referred to as podagra and they involve inflammation, swelling, pain and a sensation of burning. Podagra can also occur due to acquired injuries or intense physical effort that involves the lower limbs.

Apart from the region of the toes, recurrent attacks also involve pain and inflammation of the knees, elbows, shoulders, wrists and fingers. Most types of gout attacks can generate low to moderate fever and sweating.

And when gout becomes chronic, the damage to the joint is deforming and crippling. Chronic gout attacks are usually long-lasting and they occur in multiple regions of the body.

What are the main symptoms of Gout?
The main symptoms of gout are severe pain and swelling in joints. It’s the crystallized and lodged of uric acid in the joints that cause joint pain. The joint gets hot, swollen and tender. In most cases, the pain attacks seem to amplify at night causing sleeping difficulty to many patients. How long can gout pain remain? The pain may remain anywhere from a few minutes to a few hours and in some cases, even days. As the disease progresses, the duration of gout attacks can exceed 7-10 days.

Other common gout symptoms include fever, discomfort, sourness, malaise, tachycardia, elevations in skin temperature, itching sensations, body aches, water retention, inflammation and intense pain of the affected area – gout in the knee cause joint pain in the knee whereas gout in the finger or toe cause pain in finger or toe. The skin in the affected regions often looks stretched. Gouty arthritis may also cause back pain since it affects the joints.

There are few therapies available for treating gout.  Fortunately gout attacks subside within a period of a week or so and gout attacks are less frequent.  There may be period ranging from months to even years between two gout attacks.

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Osgood Schalatter Disease

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Definition of Osgood Schalatter Disease

Osgood Schlatter disease is a disorder of the lower front of the knee where the large tendon under the kneecap (patellar tendon) attaches to the bone of the leg below. The condition is characterized by localized pain and tenderness in this area. Osgood-Schlatter disease is predominantly seen in young adolescent boys. It is felt that stress on the bone from the tendon tugging it during activities leads to Osgood-Schlatter disease.

What are symptoms of Osgood Schlatter disease?
Osgood Schlatter disease is felt to be due in part to recurrent pulling tension on the kneecap tendon by the bulky muscles of the front of the thigh. The irritation of this pulling can cause local pain, inflammation, swelling, and calcification of the tendon that is visible with an x-ray test.

How is Osgood Schlatter disease diagnosed?
Osgood Schlatter disease can be diagnosed clinically based on the typical symptoms and physical examination findings. X-ray testing is sometime performed in order to document the status of the calcification at the insertion of kneecap (patellar) tendon. Sometimes a tiny piece of the bone of the tibia actually is pulled away by the inflamed tendon.

What are the treatment for Osgood Schalatter disease?
Patients with Osgood Schlatter disease can be helped by anti inflammation and pain-relieving medications, ice, and rest. Osgood-Schlatter disease typically goes away over time (months to years after the normal bone growth stops). Some adults who have had Osgood-Schlatter disease are left with “knobby” appearance to the front of the knee.

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Shin Splints

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Shin splints are injuries to the front of the outer leg. While the exact injury is not known, shin splints seem to result from inflammation due to injury of the tendon (posterior peroneal tendon) and adjacent tissues in the front of the outer leg.

Shin splints are a member of a group of injuries called “overuse injuries.” Shin splints occur most commonly in runners or aggressive walkers.

What are Shin splints symptoms?
Shin splints cause pain in the front of the outer leg below the knee. The pain of shin splints is characteristically located on the outer edge of the mid region of the leg next to the shinbone (tibia). An area of discomfort measuring 4-6 inches (10-15 cm) in length is frequently present. Pain is often noted at the early portion of the workout, then lessens, only to reappear near the end of the training session. Shin splint discomfort is often described as dull at first. However, with continuing trauma, the pain can become so extreme as to cause the athlete to stop workouts altogether.

What causes Shin Splints?
A primary culprit causing shin splints is a sudden increase in distance or intensity of a workout schedule. This increase in muscle work can be associated with inflammation of the lower leg muscles, those muscles used in lifting the foot (the motion during which the foot pivots toward the tibia). Such a situation can be aggravated by a tendency to pronate the foot (roll it excessively inward onto the arch).

Similarly, a tight Achilles tendon or weak ankle muscles are also often implicated in the development of shin splints.

How are Shin Splints diagnosed?
The diagnosis of shin splints is usually made during examination. It depends upon a careful review of the patient’s history and a focused physical exam (on the examination of the shins and legs where local tenderness is noted).

Specialized (and costly) tests (for example, bone scans) are generally only necessary if the diagnosis is unclear. Radiology tests, such as X-rays, bone scan, or MRI scan, can be helpful in this setting to detect stress fracture of the tibia bone.

What is the treatment of shin splints?
Previously, two different treatment management strategies were used: total rest or a “run through it” approach. The total rest was often an unacceptable option to the athlete. The run through it approach was even worse. It often led to worsening of the injury and of the symptoms.

Currently, a multifaceted approach of “relative rest” is successfully utilized to restore the athlete to a pain-free level of competition.

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Osteochondritis Dissecans

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Osteochondritis dissecans is a joint condition in which a piece of cartilage, along with a thin layer of the bone beneath it, comes loose from the end of a bone.

Caused by reduced blood flow to the end of a bone, osteochondritis dissecans occurs most often in young men, particularly after an injury to a joint. The knee is most commonly affected, although osteochondritis dissecans can occur in other joints, including your elbow, shoulder, hip and ankle.

If the loosened piece of cartilage and bone stays put, lying close to where it detached, you may have few or no symptoms of osteochondritis dissecans, and the fracture can often heal by itself. Surgical repair may be necessary if the fragment gets jammed between the moving parts of your joint.

What are the symptoms of Osteochondritis Dissecans?
Signs and symptoms of osteochondritis dissecans may include:

  • Pain. The most common symptom of osteochondritis dissecans, pain may be triggered by physical activity — walking up stairs, climbing a hill or playing sports.
  • Joint popping or locking. Your joint may pop or get stuck in one position if a loose fragment gets caught between the bones during movement.
  • Joint weakness. You may feel that your joint is “giving way” or weakening.
  • Decreased range of motion. You may be unable to straighten your leg or arm completely.
  • Swelling and tenderness. The skin around your joint may become swollen and tender.

What are the causes of Osteochondritis Dissecans?
Osteochondritis dissecans appears to be caused by a reduction of blood flow to the end of the affected bone. This may occur from repetitive trauma of small, multiple episodes of minor unrecognized injury that damage the end of the affected bone. There may also be a genetic component involved, making some people more inclined to develop the disorder.

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Plica Syndrome

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Definition of Plica Syndrome:

Often called “synovial plica syndrome,” this is a condition that is the result of a remnant of fetal tissue in the knee. The synovial plica are membranes that separate the knee into compartments during fetal development. These plica normally diminish in size during the second trimester of fetal development. In adults, they exist as sleeves of tissue called “synovial folds,” or plica. In some individuals, the synovial plica is more prominent and prone to irritation.

What is Plica Syndrome of the Knee?
The plica on the inner side of the knee, called the “medial plica,” is the synovial tissue most prone to irritation and injury. When the knee is bent, the plica is exposed to direct injury, and it may also be injured in overuse syndromes. When the plica becomes irritated and inflamed, the condition called “plica syndrome” results.

How is Plica Syndrome diagnosed?
Diagnosis is made by physical examination or at the time of arthroscopic surgery. Plica syndrome has similar characteristics to meniscal tears and patellar tendonitis, and these may be confused. A MRI may be done, but it is often not terribly helpful in the diagnosis of plica syndrome.

What is the treatment for Plica Syndrome?
Symptomatic plica syndrome is best treated by resting the knee joint and anti-inflammatory medications. These measures are usually sufficient to allow the inflammation to settle down. Occasionally, an injection of cortisone in to the knee will be helpful.

If these measures do not alleviate the symptoms, then surgical removal of the plica may be necessary. This surgical procedure is performed using an arthroscope, or a small camera, that is inserted into the knee along with instruments to remove the inflamed tissue. The arthroscopic plica resection has good results assuming the plica is the cause of the symptoms. Often a plica is seen on arthroscopic examination. Unless symptoms are consistent with plica syndrome and the plica looks inflamed and irritated, the plica is usually left alone. Plica resection during arthroscopy is only performed if the plica is thought to be the cause of symptoms.

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Knee Bursitis

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Definition of Bursitis:

A bursa is a closed fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. Bursae is plural for bursa. The major bursae are located adjacent to the tendons near the large joints, such as the shoulders, elbows, hips, and knees. When a bursa becomes inflamed, the condition is known as bursitis. Most commonly, bursitis is caused by local soft tissue trauma or strain injury, and there is no infection (aseptic bursitis). On rare occasions, the bursa can become infected with bacteria. This condition is called septic bursitis.

What is knee bursitis?
The knee joint is surrounded by three major bursae. At the tip of the knee, over the kneecap bone, is the prepatellar bursa. This bursa can become inflamed (prepatellar bursitis) from direct trauma to the front of the knee. This commonly occurs when maintaining a prolonged kneeling position. It has been referred to as “housemaid’s knee,” “roofer’s knee,” and “carpet layer’s knee,” based on the patient’s associated occupational histories. It can lead to varying degrees of swelling, warmth, tenderness, and redness in the overlying area of the knee. As compared with knee joint inflammation (arthritis), it is usually only mildly painful. It is usually associated with significant pain when kneeling and can cause stiffness and pain with walking. Also, in contrast to problems within the knee joint, the range of motion of the knee is frequently preserved.

Prepatellar bursitis can occur when the bursa fills with blood from injury. It can also be seen in rheumatoid arthritis and can occur from deposits of crystals, as seen in patients with gouty arthritis and pseudogout. The prepatellar bursa can also become infected with bacteria (septic bursitis). When this happens, fever may be present. This type of infection usually occurs from breaks in the overlying skin or puncture wounds. The bacteria involved in septic bursitis of the knee are usually those that normally cover the skin, called staphylococcus. Rarely, a chronically inflamed bursa can become infected by bacteria traveling through the blood.

How is prepatellar bursitis of the knee treated?

The treatment of any bursitis depends on whether or not it involves infection. Aseptic prepatellar bursitis can be treated with ice compresses, rest, and antiinflammatory and pain medications. Occasionally, it requires aspiration of the bursa fluid. This procedure involves removal of the fluid with a needle and syringe under sterile conditions and can be performed in the doctor’s office. Sometimes the fluid is sent to the laboratory for further analysis. Noninfectious knee bursitis can also be treated with an injection of cortisone medication into the swollen bursa. This is sometimes done at the same time as the aspiration procedure.

Septic bursitis requires even further evaluation and treatment. The bursal fluid can be examined in the laboratory to identify the microbes causing the infection. It requires antibiotic therapy, often intravenously. Repeated aspiration of the inflamed fluid may be required. Surgical drainage and removal of the infected bursa sac (bursectomy) may also be necessary.

What about the other knee bursae?

A second bursa of the knee is located just under the kneecap beneath the large tendon that attaches the muscles in front of the thigh and the kneecap to the prominent bone in front of the lower leg. This bursa is called the infrapatellar bursa, and when inflamed, the condition is called infrapatellar bursitis. It is commonly seen with inflammation of the adjacent tendon as a result of a jumping injury, hence the name “jumper’s knee.” This condition is generally treated with ice, rest, and oral anti-inflammatory and/or pain medicines.

A third bursa of the knee is called the “anserine bursa.” It is located on the lower inner side of the knee. This bursa most commonly becomes inflamed in middle-aged women. This condition is referred to as anserine bursitis. Anserine bursitis is particularly common in those who are obese. These patients can notice pain in the inner knee while climbing or descending stairs. Anserine bursitis is generally treated with ice, rest, and oral anti-inflammatory and/or pain medicines, although cortisone injections are also given.

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Baker’s Cyst

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Baker cyst is swelling caused by fluid from the knee joint protruding to the back of the knee. The back of the knee is also referred to as the popliteal area of the knee. A Baker cyst is sometimes called a popliteal cyst. When an excess of knee joint fluid is compressed by the body weight between the bones of the knee joint, it can become trapped and separate from the joint to form the fluid-filled sac of a Baker cyst. The name of the cyst is in memory of the physician who originally described the condition, the British surgeon William Morrant Baker (1839-1896).

What causes a Baker Cyst?

Baker cysts are not uncommon and can be caused by virtually any cause of joint swelling (arthritis). The excess joint fluid (synovial fluid) bulges to the back of the knee to form the Baker cyst. The most common type of arthritis associated with Baker cysts is osteoarthritis, also called degenerative arthritis. Baker cysts can occur in children with juvenile arthritis of the knee. Baker cysts also can result from cartilage tears (such as a torn meniscus), rheumatoid arthritis, and other knee problems.

A Baker cyst may cause no symptoms or be associated with knee pain and/or tightness behind the knee, especially when the knee is extended or fully flexed. Baker cysts are usually visible as a bulge behind the knee that is particularly noticeable on standing and when compared to the opposite uninvolved knee. They are generally soft and minimally tender.

What are symptoms of a Baker Cyst?
Baker cysts can become complicated by protrusion of fluid down the leg between the muscles of the calf (dissection). The cyst can rupture, leaking fluid down the inner leg to sometimes cause the appearance of a painless bruise on the inner ankle. Baker cyst dissection and rupture are frequently associated with swelling of the leg and can mimic phlebitis of the leg. A ruptured Baker cyst typically causes rapid-onset swelling of the leg.

How is a Baker Cyst diagnosed?
Baker cysts can be diagnosed by the doctor’s examination and confirmed by radiological testing (either ultrasound, injection of contrast dye into the knee followed by imaging, called an arthrogram, or MRI scan) if necessary.

How is a Baker Cyst treated?
Baker cysts often resolve with removal of excess knee fluid in conjunction with cortisone injection. Medications are sometimes given to relieve pain and inflammation.

When cartilage tears or other internal knee problems are associated, surgery can be the best treatment option. During a surgical operation, the surgeon can remove the swollen tissue (synovium) that leads to the cyst formation. This is most commonly done with arthroscopic surgery.

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Kneecap Dislocation

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Definition of Kneecap Dislocation:

Kneecap dislocation occurs when the triangle-shaped bone covering the knee (patella) moves or slides out of place. The problem usually occurs toward the outside of the leg.

What are the causes of Kneecap Dislocation?
Kneecap (patella) dislocation is often seen in women. It usually occurs after a sudden change in direction when your leg is planted. This puts your kneecap under stress.

Dislocation may also occur as a direct result of injury. When the kneecap is dislocated, it can slip sideways and around to the outside of the knee.

What are the symptoms of knee dislocation?

  • Knee appears to be deformed
  • Knee is bent and cannot straighten
  • Kneecap (patella) dislocates to the outside of the knee
  • Knee pain and tenderness
  • Knee swelling
  • “Sloppy” kneecap — you can move the kneecap too much from right to left (hypermobile patella)

The first few times this occurs, you will feel pain and be unable to walk. However, if dislocations continue to occur and are untreated, you may feel less pain and have less immediate disability. This is not a reason to avoid treatment. Kneecap dislocation damages your knee joint.

What are the first aids for Kneecap Dislocation?
If you can, straighten out the knee. If it is stuck and painful to move, stabilize (splint) the knee and get medical attention.

Your health care provider will examine the knee, which could confirm that the kneecap is dislocated.

A knee x-ray and, sometimes, MRIs should be done to make sure that the dislocation did not cause a bone to break or cartilage to be damaged. If tests show that you have no such damage, your knee will be placed into an immobilizer or cast to prevent you from moving it for several weeks (usually about 3 weeks).

After this time, physical therapy can help build back your muscle strength and improve the knee’s range of motion.

If the knee remains unstable, you may need surgery to stabilize the kneecap. This may be done using arthroscopic or open surgery.

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Chondromalacia Patella

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Chondromalacia Patella is a common cause of kneecap pain or anterior knee pain. Often called “Runner’s Knee,” this condition often affects young, otherwise healthy athletes.

Chondromalacia is due to an irritation of the undersurface of the kneecap. The undersurface of the kneecap, or patella, is covered with a layer of smooth cartilage. This cartilage normally glides effortlessly across the knee during bending of the joint. However, in some individuals, the kneecap tends to rub against one side of the knee joint, and the cartilage surface become irritated, and knee pain is the result.

What happens to the cartilage with chondromalacia?
Chondromalacia is due to changes of the deepest layers of cartilage, causing blistering of the surface cartilage. The pattern of cartilage damage seen with chondromalacia is distinct from the degeneration seen in arthritis, and the damage from chondromalacia is thought to be capable of repair, unlike that seen with arthritis.

Who gets chondromalacia?
Chondromalacia is interesting in that it often strikes young, otherwise healthy, athletic individuals. Women are more commonly affected with chondromalacia. Exactly why this is the case is unknown, but it is thought to have to do with anatomical differences between men and women, in which women experience increased lateral forces on the patella.

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Patella Tendonitis

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Patellar tendinitis is a common overuse injury. It occurs when repeated stress is placed on the patellar tendon. The stress results in tiny tears in the tendon, which the body attempts to repair. However when the tears in the tendon increase faster than what the body can recover, it causes the inflammation in the tendon to worsen.

HOW IS PATELLAR / QUADRICEPS TENDINITIS DIAGNOSED?

Physical examination by applying pressure to different parts of the knee determines exactly where the pain is. Pain associated with patellar tendinitis usually concentrates on the front part of the knee, just below the kneecap. Ultrasound is also used to reveal the location of tears in the patellar tendon. However MRI can reveal more subtle changes in the patellar tendon.

WHAT ARE THE CAUSES?

Repeated jumping is the most common cause of patellar tendinitis. Sudden increases in the intensity of physical activity or increases in frequency of activity also add stress to the tendon. Additionally, being overweight or obese increases the stress on the patellar tendon which in turn increases the risk of patellar tendinitis.

WHAT ARE THE TREATMENTS?

Treatment includes resting which means to avoid running and jumping, massaging the patellar tendon which encourages tendon healing and strengthening the tendon by strengthening exercises which involve lowering weight slowly after raising it, such as a seated knee extension exercise.

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Meniscus Injury (Meniscal Tear)

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What is knee pain due to Meniscus Injury?

The meniscus is a small “c” shaped cartilage that acts as a cushion in the knee joint. They sit between the femur and the tibia bone, one on the outside and one on the inside of the knee. A meniscus tear occurs when the cartilage tear and are injured usually during movements that forcefully rotate the knee while weight bearing.

What is a Meniscus Tear?
A meniscus tear occurs when these pieces of cartilage tear and are injured usually during movements that forcefully rotate the knee while bearing weight. A partial or total tear of a meniscus sometimes occurs if an athlete quickly twists or rotates the upper leg while the foot is firmly planted. This often occurs in field sports such as soccer and football.

How is Meniscus Tear diagnosed?

A meniscus tear is diagnosed by taking a complete history and performs a physical exam. Pain, pops, or clicks during this test may suggest a meniscus tear. An MRI may also be done to see the extent of the tear.

What are the treatments for Meniscus Tear?

Treatment varies depending upon the extent and location of the meniscus tear. The treatment options are available from oral medications,  injection, physiotherapy, platelet rich plasma therapy and surgical intervention.

Surgical Repair for a Meniscus Tear

A large meniscus tear that causes symptoms or mechanical problems with the function of the knee joint may require arthroscopic surgery for repair. In this procedure, a small camera is inserted into the joint through a small incision, while surgical instruments are inserted into the joint through a second, small incision. With the camera, the surgeon can see the entire joint and remove and repair the torn pieces of meniscus. The goal is to save as much of the original, normal meniscus cartilage as possible.

During meniscus repair surgery the torn section of meniscus is either removed (a partial meniscectomy) or the torn edges are joined back together with suture or tacks.

Common Ask Question:
Can Meniscus Tear heal on its own?

Ans: it all depends on where the tear is located and how large. If the tear is on the outer rim or edge of the meniscus there is a blood supply and it can heal. If it is in the middle or inner edge the chances of it healing are much less. As for the surgery the latest studies indicate that you should not have the procedure done unless the knee is locking. The reason for this is in the anatomy. The meniscus sits on top of cartilage. The meniscus deepens the joint and helps control the movement of the femur on the tibia. If you take away this piece of meniscus you expose the underlying cartilage to stresses that it would not normally have. This will cause the cartilage to deteriorate which in turn causes a condition of bone on bone. This will lead to the early or premature need for a total knee replacement. What you should be doing is strengthening the entire leg from the hip to the foot. The stronger the muscles are the less likely you are to have problems. So work on this aspect. If you are having locking of the knee or the inability to fully use the range of motion then you should be looking at a surgical answer to this problem. In either case the stronger that you make the leg the easier the recovery.

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Knee Ligament Injuries

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Ligament injuries in the knee – such as an Anterior Cruciate Ligament (ACL) — are dreaded by professional and amateur athletes alike. They can be painful and debilitating. They can even permanently change your lifestyle.

But there’s good news. While an ACL injury or other ligament damage once ended the career of many an athlete, treatment is much more successful now.

So what’s behind these feared injuries? Ligaments are tough bands of tissue that connect the bones in your body. Two important ligaments in the knee, the ACL and Posterior Cruciate Ligament (PCL),  connect the thigh bone with the bones of the lower leg. But too much stress on these ligaments can cause them to stretch too far or even snap.

ACL injury and other ligament injuries can be caused by:

  • Twisting your knee with the planted.
  • Getting hit on the knee.
  • Extending the knee too far.
  • Jumping and landing on a flexed knee.
  • Stopping suddenly when running.
  • Suddenly shifting weight from one leg to the other.

These injuries are common in soccer players, football players, basketball players, skiers, gymnasts, and other athletes.

There are four ligaments in the knee that are prone to injury.

  • The Anterior Cruciate ligament (ACL) is one of the two major ligaments in the knee. It connects the thigh bone to the shin bone. ACL injuries are a common cause of disability in the knee.
  • The posterior cruciate ligament (PCL) is the second major ligament in the knee connecting the thigh bone to the shin bone.
  • The lateral collateral ligament (LCL) connects the thigh bone to the fibula, the smaller bone of the lower leg.
  • The medial collateral ligament (MCL) also connects the thigh bone to the shin bone.

Anterior Cruciate Ligament (ACL) Injury

One of the most common knee injuries is an anterior cruciate ligament sprain or tear.

Athletes who participate in high demand sports like soccer, football, and basketball are more likely to injure their anterior cruciate ligaments.

If you have injured your anterior cruciate ligament, you may require surgery to regain full function of your knee. This will depend on several factors, such as the severity of your injury and your activity level.

About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.

Injured ligaments are considered “sprains” and are graded on a severity scale.

Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly stretched, but is still able to help keep the knee joint stable.

Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This is often referred to as a partial tear of the ligament.

Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.

Partial tears of the anterior cruciate ligament are rare; most ACL injuries are complete or near complete tears.

Causes of ACL Injuries?

The anterior cruciate ligament can be injured in several ways:

  • Changing direction rapidly
  • Stopping suddenly
  • Slowing down while running
  • Landing from a jump incorrectly
  • Direct contact or collision, such as a football tackle

Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other suggested causes include differences in pelvis and lower extremity (leg) alignment, increased looseness in ligaments, and the effects of estrogen on ligament properties.

Symptoms of ACL Injuries?

When you injure your anterior cruciate ligament, you might hear a “popping” noise and you may feel your knee give out from under you. Other typical symptoms include:

  • Pain with swelling. Within 24 hours, your knee will swell. If ignored, the swelling and pain may resolve on its own. However, if you attempt to return to sports, your knee will probably be unstable and you risk causing further damage to the cushioning cartilage (meniscus) of your knee.
  • Loss of full range of motion
  • Tenderness along the joint line
  • Discomfort while walking

Examination of ACL Injuries

  • Physical Examination and Patient History
    During your first visit, our doctor will talk to you about your symptoms and medical history.During the physical examination, our doctor will check all the structures of your injured knee, and compare them to your non-injured knee. Most ligament injuries can be diagnosed with a thorough physical examination of the knee.
  • Imaging Test – Other tests which may help our doctor confirm your diagnosis include:X-rays. Although they will not show any injury to your anterior cruciate ligament, x-rays can show whether the injury is associated with a broken bone.
  • Magnetic resonance imaging (MRI) scan. This study creates better images of soft tissues like the anterior cruciate ligament. However, an MRI is usually not required to make the diagnosis of a torn ACL.

Treatment of ACL Injuries

Treatment for an ACL tear will vary depending upon the patient’s individual needs. For example, the young athlete involved in agility sports will most likely require surgery to safely return to sports. The less active, usually older, individual may be able to return to a quieter lifestyle without surgery.

Nonsurgical Treatment
A torn ACL will not heal without surgery. But nonsurgical treatment may be effective for patients who are elderly or have a very low activity level. If the overall stability of the knee is intact, your doctor may recommend simple, nonsurgical options.

  • Bracing. Our doctor may recommend a brace to protect your knee from instability. To further protect your knee, you may be given crutches to keep you from putting weight on your leg.
  • Physical therapy. As the swelling goes down, a careful rehabilitation program is started. Specific exercises will restore function to your knee and strengthen the leg muscles that support it.

Surgical Treatment
Rebuilding the ligament: Most ACL tears cannot be sutured (stitched) back together. To surgically repair the ACL and restore knee stability, the ligament must be reconstructed. Our doctor will replace your torn ligament with a tissue graft. This graft acts as a scaffolding for a new ligament to grow on.

Grafts can be obtained from several sources. Often they are taken from the patellar tendon, which runs between the kneecap and the shinbone. Hamstring tendons at the back of the thigh are a common source of grafts. Sometimes a quadriceps tendon, which runs from the kneecap into the thigh, is used. Finally, cadaver graft (allograft) can be used.

There are advantages and disadvantages to all graft sources. You should discuss graft choices with your own orthopaedic surgeon to help determine which is best for you.

Because the regrowth takes time, it may be six months or more before an athlete can return to sports after surgery.

Procedure: Surgery to rebuild an anterior cruciate ligament is done with an arthroscope using small incisions. Arthroscopic surgery is less invasive. The benefits of less invasive techniques include less pain from surgery, less time spent in the hospital, and quicker recovery times.

Unless ACL reconstruction is treatment for a combined ligament injury, it is usually not done right away. This delay gives the inflammation a chance to resolve, and allows a return of motion before surgery. Performing an ACL reconstruction too early greatly increases the risk of arthrofibrosis, or scar forming in the joint, which would risk a loss of knee motion.

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Knee Osteoarthritis

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Knee pain is a common problem in Asia, especially in individuals above the age of 40. The most common cause of knee pain is degenerative osteoarthritis. Women are more prone to the disease. It is characterized by mild to debilitating pain. The treatment ranges from physiotherapy, medication, injection and surgery. Once the condition is diagnosed, it is important to choose the treatment according to the individual’s age, and the severity of the symptoms.

Knee osteoarthritis

 

Symptom of Osteoarthritis:

The symptoms of osteoarthritis are mainly pain, swelling, and stiffening of the knee. Osteoarthritis develops slowly, but may present with sudden attacks of knee pain.

Diagnose Osteoarthritis:

An individual must be diagnosed by a doctor. After a physical examination and full detailing symptoms, the physician may also recommend X-rays to confirm presence of the disease. X-rays are very helpful in the diagnosis and may be the only special test required in the majority of cases.

Prevention Osteoarthritis:

You can take steps to help prevent osteoarthritis. If you already have arthritis, these same steps may keep it from getting worse.

Stay at a healthy weight or lose weight if you need to. Extra weight puts a lot of stress on the large, weight-bearing joints such as the knees, the hips, and the balls of the feet. Too much weight can also change the normal shape of the joint, which can increase your risk for arthritis.

– Be active . A lack of exercise can cause your muscles and joints to become weak. But light to moderate exercise can help keep your muscles strong, reduce joint pain and stiffness, and slow the time it takes for arthritis to get worse. For example, if your quadriceps (the muscles in the front of your thigh) is weak, you may be more likely to get arthritis of the knee. Regular exercise will improve the quality of the cartilage.

– Protect your joints. When you can, try not to do tasks that put repeated stress on your joints, such as kneeling, squatting. And try to use the largest joints or strongest muscles to do things. A single major injury to a joint or several minor injuries can damage cartilage over time. For example, young adults who have had a serious knee injury are more likely to get arthritis.

Exercise is one of the best things you can do to help prevent arthritis from getting worse. It can help keep your muscles strong and reduce joint pain and stiffness. And it can help you reach and stay at a healthy weight.

But you want to make sure that you don’t hurt your joints when you exercise. Before you get started, ask your doctor what kind of activity would be good for you.

Patient with ligament or meniscus injury need to be treated because these will predispose to osteoarthritis.

These tips can help you exercise safely:

– Pace yourself, especially if you haven’t exercised for a while. Start slowly, and don’t push yourself too hard. Then work your way up to where you can exercise for a longer time or do the exercise with more effort.

– Use medicine. If your joint pain gets worse after exercise, you may want to take an over-the-counter pain medicine before you exercise, such as acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or aspirin. After you’re done, ice the joints that hurt.

– Rest your joints if they are swollen. For example, if your knees are swollen, don’t use the stairs for a few days. Walk a shorter distance, and switch to swimming or riding an indoor bike.

Know when you have sore muscles and not joint pain. If your muscles are sore, you can safely exercise through the soreness. (You could exercise through joint pain too, but it’s not safe to do so.)

If you have joint pain that lasts for more than a day after you exercise, you need to:

– Rest the joint until your pain gets back to the level that is normal for you.

– Exercise for less time or with less effort.

– Try another exercise that doesn’t cause pain.

Treatment for Osteoarthritis:

Weight management to relieve stress on weight-bearing joints, Glucosamine Sulphate 1500mg per day, Anti-inflammatory drugs and analgesics, Platelet Rich (PRP) Plasma TherapyInjection of lubricants into the knee, Arthroscopy to wash away the inflamed fluid, debris and loose fragments inside the joint, Total knee replacement (used when severe osteoarthritis is present).

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Child Orthopaedics

Many parents are concerned with the normal development of their children’s feet making them amongst some of the most common conditions that doctors see. Some may be part of growing up and will usually self-correct. Others require treatment that may range from something as simple as special shoes to surgery.

Some of the more common conditions of the feet that we see are:

  • Flatfeet
  • Clubfeet
  • Abnormally shaped feet
  • Curly toes
  • Ingrown toenail
  • Extra or missing toes
  • Lumps and bumps over the foot
  • Foot pain

A doctor will be able to help differentiate between these conditions and advise treatment in a timely manner.

Conditions of the Legs

Parents have many queries on whether the way the child walks is normal and if the placement of the feet during walking is normal. Some of these variants in walking patterns can be part of development yet some may be a sign of growth abnormalities.

The way the leg aligns can also vary with age. But if the alignment is abnormal, early treatment may be required.

Some of the more common conditions of the legs are:

  • Bowleggedness
  • Knock knees
  • Unstable walking
  • Walking on the toes (tiptoeing)
  • Unequal leg lengths

Conditions of the Hips

Limping is a very common observation in children. Most times, limps are due to excessive activity and do resolve on their own. But at other times, depending on the age of the child, limping more often than not is usually secondary to problems in the hips.

Other than limping, hip conditions can present with different patterns of walking such as in-toeing and out-toeing. These patterns can be a result of normal development or it can be due to some underlying abnormality.

Newborns are also screened for a condition where the hip may be poorly or under developed or even dislocated. This is called Developmental Dysplasia of the Hips. It is important to diagnose this condition early, as treatment is simple in the early stages, requiring braces or casting. If the chance for early treatment is missed, these children may require more invasive methods such as surgery to remedy it.

Some of the hip conditions that are seen are:

  • Developmental Dysplasia of the Hips
  • In-toeing
  • Out-toeing
  • Painful and painless limps in different age groups

Osgood Schlatter disease
Irritation and inflammation of the growth plate at the top of the shin bone where the patella tendon inserts. This condition occursduring periods of rapid growth. It is treated by stretching and strengthening exercises of the hamstrings and quadriceps, and through activity modification.

Sinding-Larsen-Johansson syndrome
Also known as Jumpers Knee, it is the inflammations and irritation of the growth plate at bottom of the patella, where the patella tendon inserts. This condition usually happens during periods of rapid growth. Treatment is similar to that for Osgood Schlatter disease.

Sever’s disease
It is the irritation and inflammation of the growth plate at the back of the heel bone where the Archilles tendon inserts. Treatment consists of rest, ankle stretching and strengthening exercises and heel pads.

Inpatient (Surgical Treatment)

We do almost all Orthopaedic related surgeries such as:

Spine Surgery:

  • Fenestration and Discectomy
  • Laminectomy
  • Pedicle Screw Fixation
  • Spine Fusions
  • Bone Grafting

Knee Surgery:

  • Partial and Total Knee Replacement
  • Knee Arthroscopic and ACL Reconstruction
  • Knee Arthroscopic and Meniscus Repair
  • Knee Arthoscopic and Lateral Release
  • Knee Arthroscopic, Debridement and Microfracture
  • Tension Band Wiring of Patella

Shoulder Surgery:

  • Open Reduction Internal Fixation (ORIF) of AC Joint (Acromioclavicular Joint)
  • Shoulder Arthroscopic and Rotator Cuff Repair
  • Shoulder Arthroscopic and Bankart Repair
  • Manipulation Under Anaesthesia for Frozen Shoulder
  • Shoulder Hemiarthroplasty

Elbow Surgery:

  • Open Reduction Internal Fixation (ORIF) of Elbow
  • Release of Golfer Elbow / Tennis Elbow
  • Incision & Drainage of Bursae

Hand and Wrist Surgery:

  • Release of Trigger Finger
  • Release of Carpal Tunnel Syndrome
  • Release of Dequervain Tenosynovitis
  • Close Reduction and Kwire of Finger
  • Open Reduction Internal Fixation of Finger

Hip Surgery:

  • Partial and Total Hip Joint Replacement
  • Hip Hemiarthroplasty
  • Hip Arthroscopic

Foot and Ankle:

  • Close Reduction and Kwire of Toe
  • Open Reduction Internal Fixation of Ankle
  • Ankle Fusion
  • Ankle Arthroscopic

General Surgery:

  • Removal of Ingrown Toenail (Partial Wedge Resection)
  • Removal of Plantar Warts (Corn)
  • Removal of Lumps (Ganglion, Lipoma)
  • Fixation of all Fractures